Post-Operative Auto-Transfusion in Total Hip or Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

Background

Total hip or knee arthroplasty is an elective procedure that is usually accompanied by substantial blood loss, which may lead to acute anemia. As a result, almost half of total joint arthroplasty patients receive allogeneic blood transfusions (ABT). Many studies have shown that post-operative auto-transfusion (PAT) significantly reduces the need for ABT, but other studies have questioned the efficacy of this method.

Methods

The protocol for this trial and supporting CONSORT checklist are available as supporting information; see Checklist S1. To evaluate the efficacy of PAT, we conducted a Cochrane systematic review that combined all available data from randomized controlled trials. Data from the six included trials were pooled for analysis. We then calculated relative risks with 95% confidence intervals (CIs) for dichotomous outcomes and mean differences with 95% CIs for continuous outcomes.

Findings and Conclusion

To our knowledge, this is the first meta-analysis to compare the clinical results between PAT and a control in joint replacement patients. This meta-analysis has proven that the use of a PAT reinfusion system reduced significantly the demand for ABT, the number of patients who require ABT and the cost of hospitalization after total knee and hip arthroplasty. This study, together with other previously published data, suggests that PAT drains are beneficial. Larger, sufficiently powered studies are necessary to evaluate the presumed reduction in the incidence of infection as well as DVT after joint arthroplasty with the use of PAT.     

Hip joint replacement surgery for idiopathic osteoarthritis aggregates in families

In order to determine whether there is a genetic component to hip or knee joint failure due to idiopathic osteoarthritis (OA), we invited patients (probands) undergoing hip or knee arthroplasty for management of idiopathic OA to provide detailed family histories regarding the prevalence of idiopathic OA requiring joint replacement in their siblings. We also invited their spouses to provide detailed family histories about their siblings to serve as a control group. In the probands, we confirmed the diagnosis of idiopathic OA using American College of Rheumatology criteria. The cohorts included the siblings of 635 probands undergoing total hip replacement, the siblings of 486 probands undergoing total knee replacement, and the siblings of 787 spouses. We compared the prevalence of arthroplasty for idiopathic OA among the siblings of the probands with that among the siblings of the spouses, and we used logistic regression to identify independent risk factors for hip and knee arthroplasty in the siblings. Familial aggregation for hip arthroplasty, but not for knee arthroplasty, was observed after controlling for age and sex, suggesting a genetic contribution to end-stage hip OA but not to end-stage knee OA. We conclude that attempts to identify genes that predispose to idiopathic OA resulting in joint failure are more likely to be successful in patients with hip OA than in those with knee OA.     

Hip joint replacement surgery for idiopathic osteoarthritis aggregates in families

In order to determine whether there is a genetic component to hip or knee joint failure due to idiopathic osteoarthritis (OA), we invited patients (probands) undergoing hip or knee arthroplasty for management of idiopathic OA to provide detailed family histories regarding the prevalence of idiopathic OA requiring joint replacement in their siblings. We also invited their spouses to provide detailed family histories about their siblings to serve as a control group. In the probands, we confirmed the diagnosis of idiopathic OA using American College of Rheumatology criteria. The cohorts included the siblings of 635 probands undergoing total hip replacement, the siblings of 486 probands undergoing total knee replacement, and the siblings of 787 spouses. We compared the prevalence of arthroplasty for idiopathic OA among the siblings of the probands with that among the siblings of the spouses, and we used logistic regression to identify independent risk factors for hip and knee arthroplasty in the siblings. Familial aggregation for hip arthroplasty, but not for knee arthroplasty, was observed after controlling for age and sex, suggesting a genetic contribution to end-stage hip OA but not to end-stage knee OA. We conclude that attempts to identify genes that predispose to idiopathic OA resulting in joint failure are more likely to be successful in patients with hip OA than in those with knee OA.     

Palmar shelf arthroplasty, the next generation: distraction/interposition for rheumatoid arthritis of the wrist

Rheumatoid arthritis affects approximately 1 percent of the adult population. Bilateral symmetric involvement of the wrist occurs in 85 percent of these patients, with recurrent flares and relentless progression. Anatomic changes consist of radiocarpal, intercarpal, and radioulnar subluxation and joint destruction. For advanced disease, both wrist arthrodesis and arthroplasty have been recommended. Arthrodesis has been successful for pain relief at the expense of motion. Implant arthroplasty has been unreliable, with failure rates of 25 to 50 percent at 2 to 9 years. Palmar shelf arthroplasty was introduced in 1970 as a resectional fibrous arthroplasty. The results were good but the series was small. Subsequent reports of this procedure have been inconsistent. In 1990, I initiated and have since followed a series of patients treated with the palmar shelf arthroplasty. To the basic procedure, I added joint distraction by external fixator, collagen/bone wax interposition, scapholunate stabilization, and increased immobilization time. Fourteen consecutive patients were enrolled in this study. Each carried a diagnosis of rheumatoid or psoriatic arthritis of the wrist. There were 11 women and 3 men. Age ranged from 28 to 56 years. Follow-up ranged from 2 to 7 years (average 4.2). The patients were interviewed, examined, and x-rayed. A questionnaire using an analog scale as well as the Hospital for Special Surgery scoring system was completed to assess the clinical outcome of the wrist postoperatively compared with its preoperative status and with the contralateral wrist. No patient has requested or required a revision procedure. All patients experienced improvement with both pain and function; no wrist spontaneously fused. Patient satisfaction was high. Patients with ipsilateral arthroplasty and contralateral arthrodesis preferred the arthroplasty. Hospital for Special Surgery score increased from 53 to 91 out of 100 points (p < 0.001). Range of motion averaged 50 degrees flexion, 30 degrees extension. Palmar shelf arthroplasty remains a viable option for severe rheumatoid disease of the wrist. Ideally, the procedure is performed on the dominant wrist of a patient with bilateral wrist involvement in the setting of inflammatory arthritis.     

Use of Anti-Granulocyte Scintigraphy with 99mTc-Labeled Monoclonal Antibodies for the Diagnosis of Periprosthetic Infection in Patients after Total Joint Arthroplasty: A Diagnostic Meta-Analysis

The accurate diagnosis of periprosthetic joint infections (PJI) is crucial for therapy and the prevention of complications. No diagnostic test of PJI is 100% accurate. The aim of this study was to assess the use of anti-granulocyte scintigraphy using 99 mTc-labeled monoclonal antibodies to diagnose PJI after total joint arthroplasty. A systematic search of all relevant studies published through January 2013 was conducted using the MEDLINE, EMBASE, OVID, and ScienceDirect databases. Observational studies that assessed the accuracy of the anti-granulocyte scintigraphy with monoclonal antibodies or antibody fragments labeled with technetium 99 m in diagnosis for PJI and provided data on specificity and sensitivity were identified. Standard methods recommended for meta-analysis of diagnostic accuracy were used. Nineteen studies were eligible for inclusion. The results demonstrated that the area under the summary receiver operator curve was 0.88, and the diagnostic accuracy (Q*) was 0.81. Additionally, the diagnostic odds ratio (DOR) was 18.76 with a corresponding 95% confidence interval of 10.45–33.68. The pooled sensitivity and specificity of the diagnostic method for the diagnosis of PJI were 83% and 79%, respectively, while the pooled positive likelihood ratio (PLR) was 3.56, and the negative likelihood ratio (NLR) was 0.26. Anti-granulocyte scintigraphy using 99 mTc-labeled monoclonal antibodies has a reasonable role in the diagnosis of PJI after total joint arthroplasty. Due to the limitations of the present meta-analysis, additional high-quality original studies are required to confirm the predictive value.     

Staged Reimplantation of a Total Hip Prosthesis After Co-infection with <Emphasis Type="Italic">Candida tropicalis</Emphasis> and <Emphasis Type="Italic">Staphylococcus haemolyticus</Emphasis>: A Case Report

Fungal prosthetic joint infection is a rare complication in total joint arthroplasty. There are no established guidelines for management of these infections. We present a case of a 53-year-old male with a hip joint prosthesis co-infected with Candida tropicalis and Staphylococcus haemolyticus. A two-stage exchange arthroplasty was performed. The patient underwent implant removal, debridement, irrigation with saline solution and application of cement spacer impregnated with vancomycin followed by aggressive antimicrobial treatment in first stage. Complete eradication of infection was demonstrated by negative culture of sonicated cement spacer fluid and negative 16S rRNA and 18S rRNA gene PCR of sonicate fluid, synovial fluid and periprosthetic tissue samples. He underwent second-stage revision hip arthroplasty after 9 months of the first stage. At the latest follow-up, there was no evidence of recurrence of infection. This case illustrates the utility of sonication of biomaterials and molecular techniques for microbiological confirmation of absence of infection in staged surgeries which is required for a successful outcome.     

Culture and PCR analysis of joint fluid in the diagnosis of prosthetic joint infection

This prospective study compared PCR and culture techniques in the diagnosis of prosthetic joint infection (PJI). We obtained joint fluid samples (JFS; n=115) from patients who had failed total joint arthroplasty between January 2003 and June 2005; 49 were positive for PJI according to established strict criteria. JFS were analyzed by PCR (n=35; control n=66) or culture (n=46, control n=48). PCR was positive in 71% of PJI cases, resulting in sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and likelihood ratio for positive results as follows: 0.71; 0.97; 0.88; 0.93; 0.87 and 23.6, respectively. Culture was positive in 44% of PJI samples. Corresponding statistics were 0.44; 0.94; 0.69; 0.87; 0.63 and 7.0, respectively. Significantly higher sensitivity, accuracy and negative predictive values were calculated for PCR versus culture, and there was 83% concordance between the results of intraoperative culture and PCR detection of causative bacteria. Therefore, we conclude that PCR analysis of synovial fluid increases the utility of pre-operative aspiration for patients who require revision total joint surgery.     

News in Brief

Total hip and knee arthroplasties are commonly performed orthopedic procedures that involve a complex interaction between the prosthetic device and its surrounding biological environment. Recent developments in the field of proteomics have enabled a better understanding of these interactions in patients with a total joint arthroplasty and have the potential to lead to development of novel diagnostic and therapeutic modalities that may improve the care of these patients, particularly those who have developed complications of wear, osteolysis, loosening and periprosthetic joint infection. This article reviews several of the areas of active research that are occurring at the intersection of the fields of proteomics and total joint arthroplasty.     

Total Hip Replacement in Inflammatory Hip Disease using the Charnley Prosthesis

The Charnley low-friction arthroplasty was performed on 73 hips in 55 patients with inflammatory joint disease, usually for intolerable pain. Sixty-five of these operations were reviewed at a special clinic or by postal questionnaire; 57 hips were painfree or gave rise to only occasional discomfort, in 58 there was an increased range of movement, and in 46 of the 59 hips assessed clinically, the results were excellent or good. The most serious complication was deep infection, which occurred in 7 operations.     

Total hip arthroplasty.

Total hip arthroplasty, or surgical replacement of the hip joint with an artificial prosthesis, is a reconstructive procedure that has improved the management of those diseases of the hip joint that have responded poorly to conventional medical therapy. In this review we briefly summarize the evolution of total hip arthroplasty, the design and development of prosthetic hip components, and the current clinical indications for this procedure. The possible complications of total hip arthroplasty, its clinical performance over time, and future directions in hip replacement surgery are also discussed.     

Treatment of chronic infected hip arthroplasty wounds by radical debridement and obliteration with pedicled and free muscle flaps

Nine patients with extensive wounds of the hip joint due to chronic infection following total hip arthroplasty or internal fixation of fractures of the femoral head and neck have been treated by serial radical debridements to remove infected bone, contaminated remnants of bone cement, and the surrounding fibrotic soft tissues. The resultant deep cavity extending down to the acetabulum has then been obliterated with either pedicled muscle flaps or free muscle flaps. Subcutaneous or transpelvic transposition of rectus abdominis muscle flaps is preferred for smaller defects, but only the free latissimus dorsi muscle flap provides sufficient volume of tissue to obliterate the more extensive hip defects. Systemic antibiotics have been continued only for a short-term course of 14 days postoperatively. There has been no recurrence of infection, with follow-up ranging between 6 months and 3 1/4 years. One patient has undergone reimplantation of a second custom hip prosthesis into the vascularized bed of a free latissimus dorsi muscle flap.     

A Systematic Review and Meta-Analysis of Antibiotic-Impregnated Bone Cement Use in Primary Total Hip or Knee Arthroplasty

Background

Antibiotic-impregnated bone cement (AIBC) has been widely used for the treatment of infected revision arthroplasty, but its routine use in primary total joint arthroplasty (TJA) remains considerably controversial. With this meta-analysis of published randomized controlled trials, we intended to assess the antimicrobial efficacy and safety of AIBC for its prophylactic use in primary TJA.

Methods

A literature search was performed in MEDLINE, Embase, CBMdisc and the Cochrane Library until June, 2013. The studies were divided into two sub-groups according to the type of the control group. Outcomes of interest included postoperative infection rates, radiographic outcomes and clinical joint score. Study quality was evaluated using the Jadad scale (five points).

Results

In total, eight studies were included, with a sample size of 6,381 arthroplasties. The overall pooled data demonstrated that, compared with the control (plain cement or systemic antibiotic), AIBC did not reveal an advantage in decreasing the rate of superficial infection (relative risk [RR] = 1.47; 95% CI, 1.13–1.91; P=0.004), while there were significant differences in deep infection rate between the AIBC and control group (RR = 0.41; 95% CI, 0.17–0.97; P=0.04). For the analysis of gentamicin and cefuroxime subgroups, the gentamicin was superior to the cefuroxime in reducing deep infection rate (P=0.0005 versus P= 0.10). However, no significant differences were found in their radiographic outcomes and clinical joint score.

Conclusion

This meta-analysis had proven that the prophylactic use of AIBC could lower the deep infection rate in primary TJA, while AIBC did not show an improvement in reducing the superficial infection rate compared with the control. More sufficiently powered studies would be required to further evaluate the efficacy and safety of AIBC for primary TJA.     

Effects of episodic subluxation events on third body ingress and embedment in the THA bearing surface

In total joint arthroplasty, third body particle access to the articulating surfaces results in accelerated wear. Hip joint subluxation is an under-recognized means by which third body particles could potentially enter the otherwise closely conforming articular bearing space. The present study was designed to test the hypothesis that, other factors being equal, even occasional events of femoral head subluxation greatly increase the number of third body particles that enter the bearing space and become embedded in the acetabular liner, as compared to level-walking cycles alone. Ten metal-on-polyethylene hip joint head-liner pairs were tested in a multi-axis joint motion simulator, with CoCrMo third body particles added to the synovial fluid analog. All component pairs were tested for 2h of level walking; half were also subjected to 20 intermittent subluxation events. The number and location of embedded particles on the acetabular liners were then determined. Subluxation dramatically increased the number of third body particles embedded in the acetabular liners, and it considerably increased the amount of scratch damage on the femoral heads. Since both third body particles and subluxation frequently occur in contemporary total hip arthroplasty, their potent synergy needs to be factored prominently into strategies to minimize wear.     

Utility of Intraoperative Frozen Section in the Diagnosis of Periprosthetic Joint Infection

Purpose

Intraoperative frozen section (FS) is an effective diagnostic test for periprosthetic joint infection (PJI). We evaluated the diagnostic characteristics of single- and multiplex-site intraoperative FS, and evaluated the results of single-site FS combined with those of C-reactive protein (CRP) level and erythrocyte sedimentation rate (ESR) for assessing PJI.

Methods

We studied 156 painful joint arthroplasties in 152 consecutive patients presenting for revision total joint arthroplasty due to PJI. Receiver operating characteristic analysis was used to determine the optimal cutoff values for CRP level, ESR, and intraoperative FS histopathology. Sensitivity, specificity, positive and negative predictive values, and accuracy of the diagnostic tests were assessed using a 2×2 table.

Results

We investigated the diagnostic utility of polymorphonuclear leukocyte number (PMN) per high-power field (HPF) on FS. Our data showed that 5 PMNs per HPF is a suitable diagnostic threshold, with a high accuracy in single- and multiplex-site FS. Five PMNs in any 1 of 5 sites had the highest sensitivity of 0.86 and a specificity of 0.96. Five PMNs in every 1 of 5 sites had greater diagnostic utility, with a specificity of 1; however, the sensitivity of this measure fell to 0.62. Five PMNs in single-site FS had a sensitivity of 0.70 and a specificity of 0.94. Five PMNs in single-site FS or CRP level ≥15 mg/L increased the sensitivity to 0.92; however, the specificity decreased to 0.79.

Conclusion

Compared with single-site FS, any 1 positive site on multiplex-site FS may improve sensitivity, while every 1 positive site on multiplex-site FS may improve specificity. Five PMNs in any 1 of 5 sites on FS has excellent utility for the diagnosis of PJI. Additional systematic large-scale studies are needed to verify this result.     

Surgery in the treatment of rheumatoid arthritis and ankylosing spondylitis

The pain, deformities and disabilities resulting from rheumatoid arthritis and ankylosing spondylitis must be treated by a team composed of physician, physical medicine expert, orthopaedic surgeon, and, in certain cases, deep X-ray therapist working simultaneously.The principle of "rest" in order to relieve pain has to be combined with methods designed to preserve and restore function. The multiple joint deformities in these cases may necessitate a long programme of reconstructive or functional treatment, which entails whole-hearted co-operation on the part of the patient in intensive post-operative exercise regime.PROCEDURES ADVOCATED FOR THE UPPER LIMB INCLUDE EXCISION OF THE ACROMION PROCESS TOGETHER WITH THE SUBACROMIAL BURSA TO ALLOW FREE MOVEMENT BETWEEN THE CENTRAL TENDON OF THE DELTOID AND THE TENDINOUS SHOULDER CUFF: arthrodesis of the shoulder in cases where there is more severe joint destruction: in certain cases of elbow-joint arthritis, excision of the radial head and sub-total synovectomy may preserve joint function and avoid or delay the necessity for arthroplasty which can be carried out in two ways: (a) similar to the formal joint excision, or (b) re-shaping the lower end of the humerus and upper end of the ulna lining these surfaces with fascia. The former method is preferable in cases of rheumatoid arthritis. To overcome wrist-joint deformity and restore pronation and supination excision of the lower end of the ulna together with radiocarpal fusion in position for optimum function is advocated. Finger and toe joints may be corrected by resection of the bone ends and capsulectomy.In the lower limbs bilateral involvement of the hip-joint is best treated by vitallium mould arthroplasty which may be carried out in four ways: (1) Routine arthroplasty; (2) Modified Whitman procedure; (3) Modified Colonna operation; and (4) The proximal shaft or intertrochanteric arthroplasty. It is essential in these operations to have knowledge of the operative technique, the use of special hip gouges and reamers, and detailed post-operative supervision.For dorsal kyphosis of the spine, spinal osteotomy at the lumbar level provides excellent correction but is an operation demanding care and skill in its execution.The author's remarks are based on experience gained when working with Dr. M. N. Smith-Petersen at the Massachusetts General Hospital, Boston, U.S.A.     

Recent advances in shoulder research

Shoulder pathology is a growing concern for the aging population, athletes, and laborers. Shoulder osteoarthritis and rotator cuff disease represent the two most common disorders of the shoulder leading to pain, disability, and degeneration. While research in cartilage regeneration has not yet been translated clinically, the field of shoulder arthroplasty has advanced to the point that joint replacement is an excellent and viable option for a number of pathologic conditions in the shoulder. Rotator cuff disease has been a significant focus of research activity in recent years, as clinicians face the challenge of poor tendon healing and irreversible changes associated with rotator cuff arthropathy. Future treatment modalities involving biologics and tissue engineering hold further promise to improve outcomes for patients suffering from shoulder pathologies.     

Adaptation of scapula lateral rotation after reverse anatomy shoulder replacement

Scapula motion is significant for support of the arm and stability of the shoulder. The effect of the humeral elevation on scapular kinematics has been well investigated for normal subjects, but there are limited published studies investigating adaptations after shoulder arthroplasty. Scapula kinematics was measured on 10 shoulders (eight subjects) with a reverse total joint replacement. The measurements were performed using an instrumented palpating technique. Every subject performed three simple tasks: abduction, elevation in scapula plane and forward flexion. Results indicate that, lateral scapula rotation was significantly increased (average of 24.42% over the normal rhythm) but the change was variable. Despite the variability, there is a clear trend correlating humeral performance with increased rotation (R2 0.829). There is clearly an adaptation in lateral scapula rotation in patients with shoulder joint replacement. The reason for this is unclear and may be related to joint pathology or to muscle adaptation following arthroplasty.     

Prehabilitation before knee arthroplasty increases postsurgical function: a case study

Conditioning the body to undergo physical stress such as joint arthroplasty has been termed prehabilitation. This case study examined the effect of a 4-week prehabilitation intervention on functional outcomes after total knee arthroplasty (TKA). Two female subjects completed baseline strength and functional assessments before TKA. Subjects were randomized to either a 4-week prehabilitation intervention (ES) aimed at increasing strength and range of motion or a usual care condition (CS). After 4 weeks of training, subjects were reassessed and underwent TKA. Subjects completed a final assessment 12 weeks after TKA. Functional outcomes included 6-minute walk, number of times up from a chair in 30 seconds, proprioception, and self-reported function and pain using the Western Ontario and McMaster Universities Osteoarthritis Index. The data suggest that 4 weeks of prehabilitation had a positive effect on functional task performance and knee proprioception before surgery. After surgery, the ES continued to exhibit higher levels of functioning and less pain compared with the CS. Prehabilitation before TKA may contribute to improved recovery after surgery.     

Salvage of jeopardized total-knee prosthesis: the role of the gastrocnemius muscle flap

Total-knee arthroplasty has provided many patients with excellent long-term functional results. However, exposure of a total-knee replacement usually eventuates in failure. The relatively superficial location of the prosthesis, the need for early active motion, previous surgical incisions, and a variety of systemic factors may militate against early wound healing. Restoration of well-vascularized soft-tissue cover can salvage an otherwise disastrous situation. The authors recommend early operative intervention upon observation of wound breakdown, devitalized skin edges, or significant subcutaneous infection leading to necrotic overlying skin. The operative procedure found to salvage the majority of prostheses consists of adequate debridement, antibiotic irrigation (of the joint, if exposed), and coverage with a well-vascularized muscle flap, preferably the medial gastrocnemius muscle. The operative technique and ultimate long-term outcome are reviewed based on experience with 10 consecutive patients presenting with a jeopardized knee prosthesis. Follow-up ranged from 1 to 6 years. Representative case histories are presented.     

膝关节炎患者关节置换术后细菌感染严重程度与IL-1β、TNF-α、IL-6水平的相关性

目的探讨膝关节炎患者关节置换术后细菌感染严重程度与IL-1β、TNF-α、IL-6水平的相关性。方法选取2016年8月至2018年8月于我院进行治疗的70例膝关节炎关节置换术后细菌感染患者作为试验组,参照Michel Lequesen推荐的膝关节炎严重性判断标准将膝关节炎关节置换术后细菌感染患者分为极严重组、非常严重组、严重组、中度组和轻度组。选取同期来我院体检中心进行体检的健康者50例为对照组。采用全自动生化免疫分析仪测定血清IL-1β、IL-6及TNF-α水平。结果试验组患者血清IL-1β、TNF-α、IL-6水平均明显高于对照组(均P<0.05)。极严重组患者血清IL-1β、TNF-α、IL-6水平显著高于非常严重组、严重组、中度组和轻度组(均P<0.05)。非常严重组患者血清IL-1β、TNF-α、IL-6水平显著高于严重组、中度组和轻度组(均P<0.05)。严重组患者血清IL-1β、TNF-α、IL-6水平显著高于中度组和轻度组(均P<0.05)。IL-1β、TNF-α、IL-6水平与膝关节炎关节置换术后细菌感染严重程度呈显著正相关(均P<0.05)。结论膝关节炎关节置换术后细菌感染患者血清IL-1β、TNF-α、IL-6水平明显升高,并且病情越严重,IL-1β、TNF-α、IL-6水平越高。