Intra-articular versus intravenous administration of tranexamic acid in lower limb total arthroplasty: a systematic review and meta-analysis of randomised clinical trials
European journal of orthopaedic surgery & traumatology : orthopedie traumatologie. 2022
AIM: The ideal route of tranexamic acid (TXA) administration in total hip arthroplasty (THA) or total knee arthroplasty (TKA) remains controversial. This study aims to identify the optima route of TXA administration in THA or TKA. METHODS PUBMED, EMBASE, MEDLINE and CENTRAL database were systematically searched until 4 August 2021 for randomised studies that compared intravenous (IV) or intra-articular (IA) administration of TXA in THA or TKA. RESULTS Sixty-seven studies enrolling 8335 patients (IA: 4162; IV: 4173) were eligible for quantitative and qualitative analysis. Comparable results were demonstrated in the incidence of venous thromboembolisation (OR:0.96, p = 0.84), total blood loss (MD: - 9.05, p = 0.36), drain output (MD: - 7.36, p = 0.54), hidden blood loss (MD: - 6.85, p = 0.47), postoperative haemoglobin level (MD: 0.01, p = 0.91), haemoglobin drop (MD: - 0.10, p = 0.22), blood transfusion rate (OR: 0.99, p = 0.87), total adverse events (OR: 1.12, p = 0.28), postoperative range of motion (MD: 1.08, p = 0.36), postoperative VAS pain score (MD: 0.13, p = 0.24) and postoperative D-dimer level (MD: 0.61, p = 0.64). IV route of TXA administration was associated with significantly longer length of hospital stay compared to IA route of administration (MD: - 0.22, p = 0.01). CONCLUSION In this meta-analysis, both IV and IA route of TXA administration were equally effective in managing blood loss and postoperative outcomes in lower limb joints arthroplasty. LEVEL OF EVIDENCE Level 1. PROSPERO Registration CRD42021271355.
Effects of Platelet-Rich Plasma on Clinical Outcomes After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis
Orthopaedic journal of sports medicine. 2022;10(1):23259671211061535
BACKGROUND Many studies have documented the use of platelet-rich plasma (PRP) alongside anterior cruciate ligament (ACL) reconstruction (ACLR) in the management of ACL injury, but evidence on the benefits of PRP in improving the clinical outcomes of ACLR is inconsistent. PURPOSE To help in our understanding, we undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) that evaluated the effects of PRP on patient-reported functional scores, the clinical assessments of knee function and structure, and complications. STUDY DESIGN Systematic review; Level of evidence, 1. METHODS We searched 9 online databases for RCTs published in English or Chinese that examined the effects of PRP on ACLR. The primary outcome measures were visual analog scale (VAS) for pain and International Knee Documentation Committee (IKDC) scores. The secondary outcomes included KT-1000 arthrometer, pivot-shift test, Lysholm and Tegner scores, tunnel widening, graft characterization, and complications. Subgroup analyses were performed according to time of assessments. Fixed- and random-effects models were selected for data analysis. RESULTS A total of 14 studies were included. When PRP was injected to graft tunnels, the pooled VAS scores of the 2 groups were similar (P = .31), and the subgroup analysis found that VAS and IKDC only improved at 3 months postoperatively (P = .0003 and P < .00001, respectively). When PRP was used at the bone-patellar tendon-bone harvest sites, VAS was decreased in the first 6 months postoperatively (P < .00001), whereas IKDC score was not remarkably different (P = .07). After PRP injection, Lysholm scores at 3 months postoperatively was different between the 2 groups (P < .00001), but the Tegner scores (P = .86), KT-1000 measurements (P = .12), the positive rate of pivot-shift test (P = .64), the enlargement of tunnels (femoral, P = .91; tibial, P = .80), and the characterization of grafts (P = .05) were not different. No difference in complications was found in either group. CONCLUSION PRP applied alongside ACLR could reduce postoperative pain and improve knee function in the short and medium terms but is ineffective in the long term. PRP does not improve knee stability and the enlargement of tunnels and does not accelerate the healing of grafts. Further studies would be required.
Perioperative intravenous iron to treat patients with fractured hip surgery: A systematic review and meta-analysis
Health science reports. 2022;5(3):e633
BACKGROUND Treatment of preoperative anemia with intravenous iron is common within elective surgical care pathways. It is plausible that this treatment may improve care for people with hip fractures many of whom are anemic because of pre-existing conditions, fractures, and surgery. OBJECTIVE To review the evidence for intravenous iron administration on outcomes after hip fracture. DESIGN We followed a predefined protocol and conducted a systematic review and meta-analysis of the use of intravenous iron to treat anemia before and after emergency hip fracture surgery. The planned primary outcome was a difference in length of stay between those treated with intravenous iron and the control group. Other outcomes analyzed were 30-day mortality, requirement for blood transfusion, changes in quality of life, and hemoglobin concentration on discharge from the hospital. DATA SOURCES EMBASE, MEDLINE, The Cochrane Library (CENTRAL, DARE) databases, Clinicaltrials.gov, and ISRCTN trial registries. Date of final search March 2022. ELIGIBILITY CRITERIA Adult patients undergoing urgent surgery for hip fracture. Studies considered patients who received intravenous iron and were compared with a control group. RESULTS Four randomized controlled trials (RCT, 732 patients) and nine cohort studies (2986 patients) were included. The RCTs were at low risk of bias, and the nonrandomized studies were at moderate risk of bias. After metanalysis of the RCTs there was no significant difference in the primary outcome, length of hospital stay, between the control group and patients receiving intravenous iron (mean difference: -0.59, 95% confidence interval [CI]; -1.20 to 0.03; I (2) = 30%, p = 0.23). Intravenous iron was not associated with a difference in 30-day mortality (n = 732, OR: 1.14, 95% CI: 0.62-2.1; I (2) = 0%, p = 0.50), nor with the requirement for transfusion (n = 732, OR: 0.85, 95% CI: 0.63-1.14; I (2) = 0%, p < 0.01) in the analyzed RCTs. Functional outcomes and quality of life were variably reported in three studies. CONCLUSION The evidence on the use of intravenous iron in patients with hip fracture is low quality and shows no difference in length of acute hospital stay and transfusion requirements in this population. Improved large, multicentre, high-quality studies with patient-centered outcomes will be required to evaluate the clinical and cost-effectiveness of this treatment.
Platelet-Rich Plasma Augmentation of Arthroscopic Rotator Cuff Repair Lowers Retear Rates and Improves Short-Term Postoperative Functional Outcome Scores: A Systematic Review of Meta-Analyses
Arthroscopy, sports medicine, and rehabilitation. 2022;4(2):e823-e833
PURPOSE The purpose of this study is to conduct a systematic review of meta-analyses of rotator cuff repair using platelet-rich plasma (PRP) to identify whether PRP improves clinical function and rate of tendon retears. We will (1) conduct a systematic review of the current meta-analyses of rotator cuff repair using platelet-rich plasma available in the literature, (2) evaluate the quality of these meta-analyses using the Preferred Reporting Items for Systematic Review (PRISMA) methodology, (3) identify whether PRP improves clinical function and rate of tendon retears, and develop guidance to improve future studies in this area. METHODS We carried out a systematic review of previous meta-analyses published on the clinical outcomes of PRP used in the treatment of rotator cuff tears. We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases, using various combinations of the commercial names of each PRP preparation and "rotator cuff" (with its associated terms), looking specifically at human meta-analysis studies involving the repair of the rotator cuff tendon surgically in the English language. Data validity was assessed and collected on clinical outcomes. Following this, a meta-analysis was undertaken. RESULTS Thirteen meta-analyses met the inclusion and exclusion criteria. All were considered of similar quality with Oxman-Guyatt index of 9 and PRISMA score of more than 24. A total of 1,800 patients with an average follow up of 12 to 36 months. The use of PRP for arthroscopic rotator cuff tear, when compared with controls, leads to a lower number of retears, improved short-term postoperative scores, and functional outcome. The following postoperative scores were reported: Constant: 12, Simple Shoulder Test: 10, ASES (American Shoulder and Elbow Surgeons): 9, UCLA (University of California, Los Angeles) 11, SANE (Single Assessment Numeric Evaluation) 1, VAS (visual analog scale): 6, and Retears: 13. Subgroup analysis showed that leukocyte content and gel application make no difference in the effectiveness of PRP. VAS score subgroup analysis showed short-term pain relief. CONCLUSIONS Our study shows that PRP is effective in reducing retears after rotator cuff repair and improving functional outcome scores and reducing short-term pain. LEVEL OF EVIDENCE Level III, systematic review of Level I-III studies.
Impact of tourniquet during total knee arthroplasty when tranexamic acid was used: a meta-analysis of randomized controlled trials
Journal of orthopaedic surgery and research. 2022;17(1):18
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.
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
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.
Do the New Protocols of Platelet-Rich Fibrin Centrifugation Allow Better Control of Postoperative Complications and Healing After Surgery of Impacted Lower Third Molar? A Systematic Review and Meta-Analysis
Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons. 2022
PURPOSE Platelet concentrate generation protocols have undergone several modifications in recent years; in light of this new development, this study review aims to evaluate the effects of platelet-rich fibrin (PRF) and the new centrifugation protocols, advanced platelet-rich fibrin (A-PRF), and leukocyte platelet-rich fibrin (L-PRF), after extraction of impacted mandibular third molar. Specifically, we assessed pain control, edema, trismus, and soft tissue healing, and also measured the degree of periodontal regeneration adjacent to the second molar. METHODS PubMed, MEDLINE, EMBASE, Web of Science, Virtual health library (BVS), and Cochrane Library were searched up to Julye 202; randomized controlled studies were included. This report followed the PRISMA statement and PICO questions. This review has been registered at PROSPERO under the number CRD42019136701. The risk of bias screening and data extraction was performed according to the guidelines recommended by Cochrane. The quantitative analysis was performed using RevMan version 5.4. RESULTS Of 17 studies included in the systematic review, 11 were eligible for the meta-analysis. The use of L-PRF was not associated with better soft tissue healing at day 7. (SMD = -0.70; 95% confidence interval, -3.50 to 2.10; Z = 0.49; P = .62; Pheterogeneity = 0.00001; I(2) = 97%). With L-PRF, qualitative analysis revealed better pocket depth and insertion level, and also better pain control at 1 and 3 days. With A-PRF, a lower consumption of analgesics was observed than with L-PRF. With both A-PRF and L-PRF, better control of edema (but not trismus) was observed. CONCLUSIONS The use of L-PRF and A-PRF allows better control of pain and edema compared with the use of standard PRF protocols, but neither has an effect on trismus. The PRF and L-PRF protocols improve soft tissue healing, although not to a statistically significant degree; however, they could improve probing depth at the third month after third molar surgery.
Cemented total knee arthroplasty shows less blood loss but a higher rate of aseptic loosening compared with cementless fixation. An updated meta-analysis of comparative studies
The Journal of arthroplasty. 2022
BACKGROUND The aim of this study was to update the current evidence on functional outcomes, complications, and reoperation rates between cemented and cementless total knee arthroplasty (TKA) by evaluating comparative studies published over the past 15 years. METHODS The PubMed, MEDLINE, Scopus, and the Cochrane Central databases were used to search keywords and a total of 18 studies were included. Random and fixed effect models were used for the meta-analysis of pooled mean differences (MDs) and odds ratios (ORs). RESULTS A total of 5222 patients were identified with a mean age of 64.4±9.4 and 63±8.6 years for the cemented and cementless TKA groups, respectively. The mean follow-up was 107.9±30 and 104.3±10 months for the cemented and cementless TKA groups, respectively. Cemented TKA showed a significantly greater postoperative Knee Society Score (MD=-0.95, 95%CI [-1.57,0.33], p=0.003) and range of motion (MD=-1.09, 95%CI [-1.88,-0.29], p=0.0007), but no differences in other outcome scores were found. The incidence of periprosthetic joint infection, radiolucent lines, instability, and polyethylene wear was also comparable. Cemented TKA showed less peri-operative blood loss (SMD=-438.41, 95%CI [-541.69,-35.14], p<0.0001) but a higher rate of manipulation under anesthesia (OR=3.39, 95%CI [1.64,6.99], p=0.001) and aseptic loosening (OR=1.62, 95%CI [1.09,2.41], p=0.02) than cementless TKA. No differences were found in terms of the reoperation rate. CONCLUSION When cemented and cementless fixation are compared in primary TKA, comparable functional outcomes and reoperation rates can be achieved. Cemented TKA showed less blood loss but a higher rate of manipulation under anesthesia and aseptic loosening.
The mid-term and long-term effects of tourniquet use in total knee arthroplasty: systematic review
Journal of experimental orthopaedics. 2022;9(1):42
PURPOSE A tourniquet is routinely used during total knee arthroplasty (TKA) to reduce intra-operative hemorrhage, though surgery without a tourniquet is becoming popular. To address concerns about the effect of blood at cement interfaces on long-term implant stability, we conducted a systematic review among patients undergoing total knee arthroplasty to determine if TKA with a tourniquet, compared to TKA without a tourniquet or with reduced tourniquet duration, is associated with better mid-term and long-term implant stability. METHODS A literature search was conducted without language restriction in PubMed, Cochrane database and Web of Science from conception to 17th March, 2021. Prospective cohorts, randomized and observational, that compared tourniquet use with a control group, followed patients for 3 months or more and reported outcomes concerning implant stability, limb function, pain and inflammation. Article selection, quality assessment according to the Revised Cochrane risk assessment scale and Newcastle Ottawa Scale, and data extraction were conducted in duplicate. PROSPERO CRD42020179020. RESULTS The search yielded 4868 articles, from which 16 randomized controlled trials (RCT) and four prospective cohort studies, evaluating outcomes of 1884 knees, were included. Eleven RCTs were evaluated to be low overall risk of bias, five RCTs had some concerns and four cohort studies were good quality. Few studies showed benefits of tourniquet use in mid-term implant stability (1/6), pain (1/11) and limb inflammation (1/5), and long-term implant stability (1/1). One study reported a significantly improved range of motion (1/14) while another reported significantly reduced quadriceps strength (1/6) in the tourniquet group. The remaining studies reported non-significant effect of tourniquet use. CONCLUSION Although few studies indicated benefits of tourniquet use in mid-term pain, limb inflammation, implant loosening and function, and long-term implant loosening, the majority of studies report no significant advantage of tourniquet use in total knee arthroplasty.
Leukocyte-Rich and Leukocyte-Poor Platelet-Rich Plasma in Rotator Cuff Repair: A Meta-analysis
International journal of sports medicine. 2022
To systematically review of randomized controlled trials(RCTs) to compared the effects of leukocyte-rich and leukocyte-poor platelet-rich plasma in arthroscopic rotator cuff repair. Two independent reviewers comprehensively searched PubMed, Embase, and Cochrane library databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Comparison of leukocyte-rich platelet-rich plasma or leukocyte-poor platelet-rich plasma in rotator cuff repair in a level I RCTs. Methodological quality assessment was carried out using Cochrane Review Manager 5.3 software. P<0.05 was considered statistically significant. Nine RCTs with 540 patients were included in this review. Meta-analysis showed that leukocyte-poor platelet-rich plasma in significantly reduced retear rate in rotator cuff repair [RR=0.56 95%CI (0.42,0.75); P＜0.05), and in clinical results, the constant score [MD=3.67, 95%CI (1.62,5.73); P=0.0005], UCLA score [MD=1.60, 95%CI (0.79,2.42); P=0.0001], ASES score [MD=2.16, 95%CI(0.12,4.20);P=0.04] were significantly improved. There was a significant result in favor of PRP for the Constant score [MD=-1.24, 95%CI(-1.50,-0.99); P＜0.00001], while SST scores were not significantly different among all groups [MD=0.21, 95%CI(-0.21,0.64); P=0.32]. In conclusion, leukocyte-poor platelet-rich plasma can improved the clinical function and reduced retear rate in arthroscopic rotator cuff repair. In contrast, the efficacy of leukocyte-rich platelet-rich plasma was not significantly improved with the exception of VAS score.