Spine‐Pelvis‐Hip Alignments in Degenerative Spinal Deformity Patients and Associated Procedure of One‐Stage Long‐Fusion with Multiple‐Level PLIF or Apical‐Vertebra Three Column Osteotomy–a Clinical and Radiographic Analysis Study

ObjectiveTo explore the spine‐pelvis‐hip alignments in degenerative spinal deformity (DSD) patients, and compare the outcomes in the procedure of long‐fusion with posterior lumbar inter‐body fusion (PLIF) or single‐level three‐column osteotomy (STO) at lower lumbar level (LLL, L₃‐S₁) and thoracolumbar levels (TLL, T₁₀‐L₂) for those patients.MethodsThis is a retrospective study. Following institutional ethics approval, a total of 83 patients (Female, 67; Male, 16) with DSD underwent long‐fusion with PLIF or STO surgery between March 2015 and December 2017 were reviewed. All of those patients were assigned into LLL and TLL groups. The average age at surgery was 65.2 years (SD, 8.1). Demographic (age, gender, BMI, and comorbidities), radiographs (both coronal and sagittal parameters) and health‐related quality of life (HRQOL) assessments were documented. The radiographic parameters and HRQOL‐related measurements at pre‐ and post‐operation were compared with paired‐samples t test, and those variables in the two groups were analyzed using an independent‐sample t test. The relationships between pelvic incidence (PI) and other sagittal parameters were investigated with Pearson correlation analysis. The Pearson χ² or Fisher''s exact was carried out for comparison of gender, incidence of comorbidities and post‐operative complications.ResultsThere were 53 and 30 patients in the LLL and TLL groups respectively. Those spino‐pelvic radiographic parameters had significant improvements after surgeries (P < 0.001). The patients in the two group with different pre‐operative thoracolumbar kyphosis (TLK, P = 0.003), PI (P = 0.02), and mismatch of PI minus lumbar lordosis (PI‐LL, P = 0.01) had comparable post‐operative radiographic parameters except PI (P = 0.04) and pelvic‐femur angle (PFA, P = 0.02). Comparing the changes of those spine‐pelvic‐hip data during surgeries, the corrections of TLK in TLL group were significant larger (P = 0.004). Pearson correlation analysis showed that there were negative relationship between PI and TLK (r = −0.302, P = 0.005), positive relationship between PI and LL (r = 0.261, P = 0.016) at pre‐operation. Those patients underwent the surgical procedure that long‐segment instrumentation and fusion with STO would have higher incidence of complications involving longer operative timing (P = 0.018), more blood loss (P < 0.001), revision surgery (P = 0.008), and cerebrospinal fluid leakage (P = 0.001). All the HRQOL scores significantly improved at final follow‐up (P < 0.001), with no difference of intra‐group.ConclusionPatients suffered de‐novo scoliosis or hyper‐kyphosis with low PI would be vulnerable to significant thoracolumbar degeneration, and have more changes of spine‐pelvis‐hip data after long‐fusion surgery, however, those with high PI would be closed to significant lumbar degeneration. Although spine‐pelvis‐hip alignments in DSD patients can be restored effectively after long‐fusion with PLIF or STO, the incidence of complications in patients underwent STO was significant higher than that in patients performed multi‐level PLIF.     

An Accuracy Comparison of Minimally Invasive Transclavicular‐Transcortical Drilling with Free‐Hand,C‐Shape and Assembly‐Type Guide Device: An In Vitro Study

ObjectivesEnsuring the accuracy of transclavicular‐transcoracoid drilling in the anatomical reconstruction of the coracoclavicular ligament complex with minimally invasive incisions remains a major problem for inexperienced surgeons. The purpose of this study was to design an assembly guide device for transclavicular‐transcoracoid drilling with minimally invasive incisions, to manufacture the finished product, and to compare its feasibility and accuracy with the existing C‐shape guide devices and free‐hand techniques.MethodsAn assembly‐type guide device was designed and produced using computer‐aided design and three‐dimensional printing. The specimen data of 54 human shoulders from 27 gross specimen (14 males and 13 females) treated by free‐hand drilling, C‐shape device drilling, and assembly‐type guide device drilling from October 2018 to January 2021 were analyzed in a controlled laboratory study. Fifty‐four human shoulder specimens were randomly assigned into free‐hand (n = 18), C‐shape (n = 18), and assembly (n = 18) groups by drawing lots for transclavicular‐transcoracoid drilling by three inexperienced surgeons. After the drilling procedure was completed and the devices were removed, the operation outcomes were assessed and evaluated. Distances from the tunnel edge to the coracoid''s medial (d _m) and lateral (d _l) edges, operation time, and tunnel location zones on the coracoid''s inferior surface of all specimens in the three groups were measured to evaluate the surgical accuracy and efficiency.ResultsAll specimens in the three groups completed the drilling operation successfully and were correctly measured. The distance differences (d _d) between d _m and d _l in the free‐hand, C‐shape, and assembly groups were 3.2 ± 1.8 mm, 1.8 ± 1.0 mm, 1.0 ± 0.8 mm, respectively. The d _d of the free‐hand group was higher than that of the other two groups (p < 0.001). The tunnel exit points on the inferior coracoid surface located in undesired zones were six (33%), one (6%), and zero in the free‐hand group, C‐shape group, and assembly‐type group, respectively (p = 0.012). The operation time in the free‐hand, C‐shape, and assembly groups were 198 ± 36 s, 256 ± 64 s, and 353 ± 88 s, respectively. The operation time of each group significantly differed from that of the others (p < 0.001).ConclusionThe assembly‐type devices may be the first choice for inexperienced surgeons while both the C shape devices and assembly‐type guide devices achieved higher accuracy than free‐hand techniques.     

The Screening of Fixation‐Related Infection in Patients Undergoing Conversion Total Hip Arthroplasty after Failed Internal Fixation of Hip Fractures: A Single‐Central Retrospective Study

ObjectiveTo evaluate the diagnostic values of preoperative plasma fibrinogen and platelet count for screening fixation‐related infection (FRI) in patients undergoing conversion total hip arthroplasty (cTHA) after failed internal fixation of hip fractures.MethodThis was a single‐center retrospective study. Data were retrospectively analyzed for 435 patients who underwent cTHA in our hospital from January 2008 to September 2020. They were divided into infected (n = 30) and non‐infected groups (n = 405) according to the 2013 International Consensus Meeting (ICM) criteria. The diagnostic sensitivity and specificity of plasma fibrinogen and platelet count were determined using receiver operating characteristic (ROC) curves. Optimal predictive cutoffs of these two markers were determined based on the Youden index. In addition, the diagnostic value of preoperative serum C‐reactive protein (CRP) and erythrocyte sedimentation rate (ESR) for screening FRI were also evaluated based on the cutoffs recommended by the 2013 ICM Criteria. Finally, the diagnostic ability of various combinations of the plasma fibrinogen and platelet count as well as serum CRP and ESR was re‐assessed.ResultsThe numbers of patients with and without FRI were 30 (6.9%) and 405 (93.1%), respectively. Areas under the ROC curves were 0.770 for fibrinogen, 0.606 for platelet, 0.844 for CRP and 0.749 for ESR. The optimal predictive cutoff of fibrinogen was 3.73 g/L, which gave sensitivity of 60.0% and specificity of 90.5%. The optimal predictive cutoff for platelet was 241.5 × 10⁹/L, which gave sensitivity of 46.7% and specificity of 83.7%. The CRP gave sensitivity of 66.7% and specificity of 92.5% with the predetermined cutoff of 10 mg/L, while the ESR gave sensitivity of 67.5% and specificity of 72.4% % with the predetermined cutoff of 30 mm/h. The combination of CRP and ESR showed high specificity of 93.2% but low sensitivity of 66.7%, while the corresponding values for CRP with fibrinogen were satisfied both for sensitivity of 80.0% and specificity of 78.7%. The combination of these four biomarkers gave sensitivity of 73.3% and specificity of 85.7%.ConclusionPreoperative serum CRP, ESR, plasma fibrinogen and platelet count have low sensitivity on their own for screening FRI in patients, but the combination of CRP with fibrinogen shows promise for that.     

Clinical Efficacy of Intra‐Articular Injection with P‐PRP Versus that of L‐PRP in Treating Knee Cartilage Lesion: A Randomized Controlled Trial

ObjectivePlatelet‐rich plasma（PRP), with different concentration of leukocytes, may lead to varying effects in the treatment of cartilage lesions. So far, current research has not shown enough evidence on this. To evaluate the clinical efficacy and safety of intra‐articular injection with pure platelet‐rich plasma (P‐PRP) versus those of leukocyte platelet‐rich plasma (L‐PRP) in treating knee cartilage lesions, we conducted a double‐blind, randomized controlled clinical trial with a larger sample and longer follow‐up period.MethodsFrom October 2019 to October 2020, 95 patients were invited to participate in our study, and 60 (63.2%) were randomized to P‐PRP (n = 30) or L‐PRP (n = 30) groups. Patients from the two groups were treated with knee intra‐articular injections of P‐PRP or L‐PRP. Visual analog scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were assessed using an unpaired t‐test for independent samples preoperatively and at 6 weeks, 12 weeks, 6 months, and 12 months after intervention.ResultsWe followed up 27 cases in the P‐PRP group and 26 cases in the L‐PRP group. No significant differences in VAS and WOMAC scores were found between the two groups before the intervention (p > 0.05). The WOMAC Pain and VAS‐Motions scores of the P‐PRP group were significantly lower than those of the L‐PRP group at 6 weeks after the intervention (p < 0.05). While the long‐term clinical efficacy of both injections was similar and weakened after 12 months, more adverse events were found in the L‐PRP group.ConclusionsThe short‐term results demonstrate a positive effect in reducing pain and improving function in patients with knee cartilage lesions in the two groups. While the P‐PRP injection showed better clinical efficacy in the early phase of postoperative rehabilitation and resulted in fewer adverse events, long‐term follow‐up showed similar and weakened efficacy after 12 months.Trial RegistrationChiCTR1900026365. Registered on October 3, 2019, http://www.chictr.org.cn/showproj.aspx?proj=43911.     

Comparison of Blood Loss between Open‐Box Prosthesis and Closed‐Box Prosthesis after Primary Total Knee Arthroplasty

ObjectiveTo compare the blood loss after procedures of primary unilateral or one‐stage bilateral total knee arthroplasty (TKA) caused by open‐box prosthesis and closed‐box prosthesis.MethodsThis was a retrospective study. Patients undergoing procedures of primary TKA between January 2017 and July 2020 in our institution were assessed for eligibility for this study. Those who were diagnosed with knee osteoarthritis and underwent primary unilateral or one‐stage bilateral TKA by using PFC Sigma PS150 (closed‐box prosthesis) or Vanguard (open‐box prosthesis) knee systems and had complete data of laboratory indexes on postoperative day (POD) 1, POD 3, and POD 5 were the interested population. At last 243 patients were enrolled, among which 88 patients were classified into the unilateral closed‐box group, 66 patients into the unilateral open‐box group, 47 patients into the one‐stage bilateral closed‐box group, and 42 patients into the one‐stage bilateral open‐box group. The perioperative management and operative techniques were almost the same for each patient, except the selection of prosthesis, which was decided according to surgeon''s preference. The baseline information, postoperative laboratory indexes tested on POD 1, POD 3, and POD 5 including hemoglobin, hematocrit, platelet, thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (APTT), and international normalized ratio (INR), the primary outcome measurements including the maximum decreased value of hemoglobin and the volume of total blood loss, and the secondary outcome measurements including the transfusion rate and the average transfused red blood cell (RBC) units were well compared between the open‐box group and the closed‐box group.ResultsThe baseline was comparable between groups, except higher preoperative levels of hemoglobin (134.43 g/L vs 126.51 g/L, P = 0.003) and hematocrit (39.92% vs 37.37%, P = 0.000) observed in the one‐stage bilateral open‐box group. The differences of postoperative coagulation function monitored by TT, PT, APTT, and INR were clinically irrelevant between groups. For patients receiving unilateral TKA, significantly higher value of decreased hemoglobin (26.06 g/L vs 21.05 g/L, P = 0.025) and significantly larger amount of total blood loss (920.34 mL vs 723.19 mL, P = 0.013) were observed in the open‐box group. For patients receiving one‐stage bilateral TKA, the open‐box prosthesis was observed to cause more hemoglobin drop (37.81 g/L vs 32.02 g/L, P = 0.071) and total blood loss (1327.26 mL vs 1177.42 mL, P = 0.247) compared to the closed‐box prosthesis, though the differences were not significant. The transfusion rate and the average transfused RBC units were not significantly different between the open‐box group and the closed‐box group no matte whether the patients were from the unilateral TKA group or from one‐stage bilateral TKA group.ConclusionThe use of open‐box prosthesis caused more hemoglobin drop and total blood loss than closed‐box prosthesis after primary unilateral or one‐stage bilateral TKA, resulting in comparable transfusion rate and average transfused RBC units between groups.     

Efficacy and Safety of Hyaluronic Acid Intra‐articular Injection after Arthroscopic Knee Surgery: A Systematic Review and Meta‐analysis

ObjectiveHyaluronic acid (HA) intra‐articular injection after arthroscopic knee surgery has been widely applied but its efficacy and safety remain controversial. The aim of this systematic review is to analyze the efficacy and safety of HA intra‐articular injection after arthroscopic knee surgery, and to compare the efficacy of HA with different molecular weights.MethodsWe conducted a systematic literature search in PubMed, Embase, Google scholar and the Cochrane library from inception to 16 September 2022 for English‐written articles, in order to identify randomized controlled trials that evaluated the clinical efficacy and/or safety of HA intra‐articular injection after arthroscopic knee surgery. Then we meta‐analyzed the outcomes of patients given intra‐articular HA injections postoperatively and control patients. We also evaluated the influence of HA with different molecular weights. In every calculation, sensitive analysis was performed. The visual analogue scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and adverse events were selected as the primary outcome measurements, while Lysholm, International Knee Documentation Committee (IKDC) and Tegner score were selected as the secondary outcome measurements. Publication bias of every outcome was evaluated using egger test.ResultsFifteen studies involving 951 knees were included and 12 of them were used to performed the meta‐analysis. The results showed no significant difference between the HA group and control group according to VAS, whether assessed at less (P = 0.90) or more than 6 months (P = 0.55). Besides, there were no statistical differences between the HA group and control group according to subgroup analysis (Ps = 0.77, 0.91 and 0.81 in anterior cruciate ligament reconstruction, meniscectomy and overall groups, respectively). Compared to control group, the overall effect of WOMAC score showed no significant differences (P = 0.25), nor did in two subgroups (P = 0.37 and P = 0.22). Outcomes measured by Lysholm (P = 0.13), IKDC (P = 0.86) and Tegner (P = 0.42) scores showed no significant differences, either. The analysis of the risk of adverse events indicated no increase in HA groups (P = 0.06). We found no significant differences between high‐ and low‐molecular‐weight HA at 6 (P = 0.96) or 12 months (P = 0.93) postoperatively. Two studies failed to pass the sensitive analysis and the reasons were discussed detailly and acceptable publication bias was observed.ConclusionsAlthough HA injection after arthroscopic knee surgery is safe, the available evidence does not support its efficacy in pain relief and functional recovery. Therefore, the application of HA injection after arthroscopic knee surgery is not recommended.     

Morphological Changes of Medial Epicondyle‐Olecranon Ligament and Ulnar Nerve in the Cubital Tunnel Syndrome: An Ultrasonic Study

ObjectiveFew studies have performed detailed ultrasound measurements of medial epicondyle‐olecranon (MEO) ligament that cause the entrapment of ulnar nerve. This study aims to comprehensively evaluate dynamic ultrasonographic characteristics of MEO ligament and ulnar nerve for clinical diagnosis and accurate treatment of cubital tunnel syndrome (CuTS).MethodsThirty CuTS patients (CuTS group) and sixteen healthy volunteers (control group) who underwent ultrasound scanning from October 2016 to October 2020 were retrospectively collected, with 30 elbows in each group. Primary outcomes were thickness at six points, length and width of MEO ligament. Secondary outcomes were thickness of ulnar nerve under MEO ligament at seven parts and the cross‐sectional area (CSA) of ulnar nerve at proximal end of MEO ligament (P_0 mm). The thickness of MEO ligament and ulnar nerve in different points of each group was compared by one‐way ANOVA analysis with Bonferroni post hoc test, other outcomes were compared between two elbow positions or two groups using independent‐samples t test.ResultsThickness of MEO ligament in CuTS group at epicondyle end, midpoint in transverse view, olecranon end, proximal end, midpoint in axial view, and distal end was 0.67 ± 0.31, 0.37 ± 0.18, 0.89 ± 0.35, 0.39 ± 0.21, 0.51 ± 0.38, 0.36 ± 0.25 at elbow extension, 0.68 ± 0.34, 0.38 ± 0.27, 0.77 ± 0.39, 0.32 ± 0.20, 0.48 ± 0.22, 0.32 ± 0.12 (mm) at elbow flexion, respectively. Compared with control group, they were significantly thickened except for proximal end at elbow flexion. MEO ligament thickness at epicondyle end and olecranon end was significantly larger than midpoint in two groups. No significant difference was found in length and width of MEO ligament among different comparisons. Ulnar nerve thickness at 5 mm proximal to MEO ligament (P_5 mm, 3.25 ± 0.66 mm) was significantly increased than midpoint of MEO ligament (Mid), distal end of MEO ligament (D_0 mm), 5 mm (D_5 mm), 10 mm (D_10 mm) distal to MEO ligament at extension in CuTS group. Compared with control group, ulnar nerve thickness at P_5 mm in CuTS group was significantly increased at extension position, at D_5 mm and D_10 mm was significantly decreased at flexion position. CSA of ulnar nerve at extension position (14.44 ± 4.65 mm²) was significantly larger than flexion position (11.83 ± 3.66 mm²) in CuTS group, and CuTS group was significantly larger than control group at two positions.ConclusionsMEO ligament in CuTS patients was thickened, which compressed ulnar nerve and caused its proximal end swelling. Ultrasonic image of MEO ligament thickness was a significant indicator for CuTS and can guide surgeons in selecting the appropriate treatment.     

Morphological Asymmetry of Pelvic Rings: A Study Based on Three‐Dimensional Deviation Analysis

ObjectiveTo evaluate the morphological asymmetry of pelvic rings existing in healthy individuals in terms of three‐dimensional (3D) geometric shapes.MethodsThis study was a retrospective self‐control study. CT images of healthy pelvises, scanned from Jan 2014 to Jan 2019, were taken from 159 subjects (88 males and 71 females) aged 20 to 59 years (39.1 ± 8.7 years). Digital pelvic ring models were reconstructed from CT images and then flipped over the corresponding sagittal planes to obtain their mirrored models. A 3D deviation analysis of a pelvic ring was conducted between the original model and its mirrored model via model registration and quantification of the geometric differences. Next, the pelvic rings were split to the left and right hipbones. The same flipping procedures as done by pelvic rings were performed for left hipbones to obtain their mirrored models. A 3D deviation analysis was also performed between the left and right hip bones. Quantitative variables representing deviation mainly included the average deviation (AD) and the maximum deviation (MD). MDs over 4 mm and 10 mm were deemed as critical levels for evaluating the severity of asymmetry as per Matta''s scoring system. The quantitative assessments of the asymmetry covered pelvic rings, bilateral hip bones and the specific anatomic regions of a hip bone.Results157 out of 159 pelvic rings (98.74%) had more than 4 mm of the MD and 27 (16.98%) of them exceeded 10 mm of the MD. The MD of pelvic rings was 1.23 times as high as that for the bilateral hip bones (7.46 mm vs. 6.08 mm, P < 0.05). The ADs of pelvic rings and bilateral hip bones were 1.28 mm and 0.94 mm, respectively (P < 0.05); 2.27% of the surface points of a pelvic ring had more than 4 mm geometric deviations compared with its mirrored model, while 0.59% (P < 0.05) of bilateral hip bones were on the same level of deviation. 119 out of 159 pelvic iliac crests (74.8%) had MDs more than 4 mm, and 15 (9.4%) reached 10 mm or more. Only 15 (9.4%) pelvises presented asymmetric features in the area of obturator foramen where the MDs exceeded 4 mm.ConclusionsPelvic asymmetry exists in the general population, but 3D geometric symmetry is present in specific anatomic regions. It implies that restoring the 3D symmetry of specific anatomic regions is more reliable than “restoring the symmetry of pelvic ring” in pelvic ring reduction or pelvic fixation design.     

Comparison of Single‐Radius with Multiple‐Radius Femur in Total Knee Arthroplasty: A Meta‐Analysis of Prospective Randomized Controlled Trials

BackgroundWhether there was clinical superiority for the single‐radius prosthesis over the multi‐radius prothesis in total knee arthroplasty (TKA) still remains to be clarified. We updated a meta‐analysis including prospective randomized controlled trials (RCTs) to compare the clinical prognosis of patients receiving single‐radius TKA (SR‐TKA) or multi‐radius TKA (MR‐TKA).MethodsWe searched the databases of PubMed, Web of Science, EMBASE, Cochrane Library, MEDLINE for eligible RCTs. Two reviewers evaluated the study quality according to the Risk of Bias tool of the Cochrane Library and extracted the data in studies individually. The extracted data included the baseline data and clinical outcome. The baseline data include the author''s name, country, and year of included studies, the name of knee prosthesis used in studies, sample size, follow‐up time, and BMI of patients. The clinical data comprised primary indicators including postoperative knee range of motion (ROM), sit‐to‐stand rest, severe postoperative scorings, such as visual analog scale (VAS), American Knee Society knee score (AKS), Oxford knee scoring (OKS), and SF‐36 Quality of Life Scale, as well as various secondary indicators of complications including anterior knee pain, postoperative infection, aseptic prosthesis loosening, and prosthesis revision. The data analysis was performed using Review Manager 5.3 software and STATA 12.0. The sensitivity analysis was performed using STATA 12.0.ResultsA total of 13 RCTs, along with 1720 patients and 1726 knees, were finally included in our present meta‐analysis. We found that patients in SR‐TKA group performed better in the sit‐to‐stand test (OR = 1.89, 95% CI: 1.05–3.41, p = 0.03) and satisfaction evaluation (OR = 3.27, 95% CI: 1.42–7.53, p = 0.005), which were only evaluated in two included RCTs. While no significant difference was found between SR‐TKA and MR‐TKA groups in terms of postoperative ROM, VAS scoring, AKS scoring, SF‐36 scoring, OKS scoring, and various complications including anterior knee pain, postoperative infection, aseptic prosthesis loosening, and prosthesis revision.ConclusionIn conclusion, our present meta‐analysis indicated that SR implants were noninferior to MR implants in TKA, and SR implants could be an alternative choice over MR implants, since patients after SR‐TKA felt more satisfied and performed better in the sit‐to‐stand test, with no significant difference in complications between SR‐TKA and MR‐TKA groups. While more relevant clinical trials with long‐term follow‐up time and specific tests evaluating the function of knee extension mechanism should be carried out to further investigate the clinical performance of SR implants.     

Adverse Tissue Reactions and Metal Ion Behavior After Small‐Head Metasul Hip Arthroplasty: A Long‐Term Follow‐Up Study

ObjectiveTo investigate the long‐term survivorship, incidence of adverse reactions to metal debris (ARMD), and metal ion behavior in patients who underwent small‐head Metasul metal‐on‐metal (MoM) total hip arthroplasty (THA).MethodsBetween February 1998 and September 2003, a retrospective study was performed on 43 consecutive patients (43 hips) who underwent unilateral cementless Metasul MoM THAs at our institution. Of them, 35 patients (nine males and 26 females) who were available for follow‐up more than 15 years after THA were enrolled in this study and underwent metal artifact reduction sequence magnetic resonance imaging (MARS‐MRI) to identify ARMD. The mean age at surgery of the patients was 59.7 years old (range, 31–83). Clinical and radiographic outcomes were evaluated retrospectively. Clinical examinations were conducted using the Harris Hip Score (HHS). Serum cobalt (Co) and chromium (Cr) ion levels and Co/Cr ratio were assessed at different postoperative periods of <5, 5–10, 11–14, and ≥15 years.ResultsThe mean follow‐up period for the 35 patients included was 18.1 years (range, 15–22). The mean HHS significantly improved from 44.6 ± 11.3 points preoperatively to 89.4 ± 7.9 points at the final follow‐up (P < 0.0001). ARMD was found in 20% of the patients using MARS‐MRI. No signs of stem loosening were found clinically or radiographically, whereas cup loosening and ARMD were observed in three patients (9%), for whom revision THAs were performed. The Kaplan–Meier survival rates with revision for any reason as the endpoint were 90.9% at 5 years, 84.8% at 10 years, 84.8% at 15 years (95% CI, 67.1–93.6), and 70.3% at 20 years (95% CI, 43.6–87.0). The survival rates with revision for ARMD as the endpoint were 100% at 5 years, 96.6% at 10 years, 96.6% at 15 years (95% CI, 77.2–99.7), and 80.1% at 20 years (95% CI, 45.3–95.2). Serum Co ion level peaked at 5–10 years after THA, which was significantly higher than that <5 years; however, it decreased to the initial level after 15 years. In contrast, serum Cr ion level significantly increased at 5–10 years and then remained almost constant. Significant differences in Cr ion levels (1.0 vs 2.0 μg/L, P = 0.024) and Co/Cr ratio (1.3 vs 0.9, P = 0.037) were found between non‐ARMD and ARMD patients at >11 years postoperatively.ConclusionOur results suggest that increased Cr ion levels and decreased Co/Cr ratio may be signs of ARMD in patients who underwent small‐head Metasul MoM THA.     

Knee Scores of Patients with Non‐Lateral Compartmental Knee Osteoarthritis Undergoing Mobile,Fixed‐Bearing Unicompartmental Knee and Total Knee Arthroplasties: A Randomized Controlled Trial

ObjectiveTo evaluate knee scores and clinical efficacies of patients with non‐lateral unicompartmental knee osteoarthritis (OA) who randomly underwent mobile‐bearing (MB) unicompartmental knee arthroplasty (UKA), fixed‐bearing (FB) UKA, and total knee arthroplasty (TKA).MethodsFrom September 2015 to February 2017, a prospective, randomized, parallel, single‐center trial of 180 patients (78 males and 102 females; 63.3 ± 6.9 years) with non‐lateral compartmental knee OA was performed in the first author‐affiliated hospital. The patients were randomly divided into three groups (each group included 60 patients) and received medial cemented Oxford phase 3 MB UKA, medial cemented Link FB UKA, or cemented DePuy Sigma PFC TKA, respectively. A similar perioperative management and fast‐track surgery program was carried out for all patients. The knee scores at 3‐year follow‐up after operation and clinical efficacies of these three groups of patients were recorded, investigated, and compared.ResultsPrimarily, compared to the TKA group, the UKA groups (MB UKA and FB UKA) had shorter operative time (median 63.2 < 67.1 min), less bleeding (8.6 < 30.0 mL), earlier resumption of walking without crutches (3.0 < 8.0 days) and walking up and down the stairs (5.0 < 10.0 days) (P < 0.001), higher FJS scores (78.0 > 74.5) (P = 0.007), better results in all knee scores (except VAS and KSS function scores) (P < 0.05), and a larger maximum flexion angle of the knee at the 3‐year follow‐up (123.0° > 96.0°) (P = 0.001). Secondarily, compared to the TKA group, the MB UKA group showed better results in the Western Ontario and McMaster Universities index (WOMAC) stiffness (83.6 > 79.6), WOMAC total (86.3 > 83.2), Oxford knee score (OKS) (20.0 < 23.0), Forgotten Joint Score (FJS) (78.5 > 74.5), and a larger maximum flexion angle of the knee (123.0 > 96.0) (P < 0.05). Moreover, the FB UKA group showed higher Hospital for Special Surgery Knee Score (HSS) (91.0 > 88.5), WOMAC stiffness (84.3 > 79.6), WOMAC function (85.2 > 81.7), WOMAC total scores (87.6 > 83.2), and a larger maximum flexion angle of the knee (119.0° > 96.0°) than the TKA group (P < 0.05). Overall, there was no significant difference in all knee scores and maximum flexion angles of the knee for the MB UKA and FB UKA groups (P > 0.05). There was one case with original bearing dislocation in MB UKA group. One patient with displacement of the femoral component caused by a fall injury, and another patient, who lost his life in a car accident, were involved in the FB UKA group. There was an infection case and an intermuscular vein thrombosis case in TKA group.ConclusionUKA showed more advantages than TKA; however, there was no significant difference between the MB UKA and FB UKA groups for treatment of non‐lateral compartmental knee OA.     

Medium‐Term Clinical Results of High‐Flexion Knee Prostheses in Patients with Rheumatoid Arthritis

ObjectiveThis study was performed to evaluate the function and satisfaction outcome of patients with rheumatoid arthritis (RA) who underwent total knee arthroplasty (TKA) with high‐flexion prostheses.Materials and methodsTwenty‐two patients (35 knees) using high‐flexion prostheses (Zimmer, Warsaw, IN) were followed up for a period of 7–11 years from February 2007 to December 2009. Clinical and radiographic follow‐up was performed using Hospital for Special Surgery (HSS), Short‐Form 36 scores (SF‐36), American Knee Society score (KSS), and Knee Society Total Knee Arthroplasty Roentgenographic Evaluation and Scoring System. Patient satisfaction assessments took place at the final follow‐up sessions using the Marsh Satisfaction Questionnaire.ResultsThe average ROM improved from preoperative 68.43° ± 33.78° to 95.54° ± 7.03° at the final follow‐up. The HSS score and KSS score for pain improved from (46.49 ± 12.73) points to (85.46 ± 3.90) points and from 20.57 ± 5.91 points to 47.43 ± 3.51 points at the follow‐up evaluation, respectively. Physical Component Summary(PCS) and Physical Component Summary (MCS) scores were 45.38 and 52.56, respectively by the end of follow‐up. Deep venous thrombosis developed in one patient and one patient required surgical revision due to infection. There were no instances of prosthetic loosening. The satisfaction rate of patients was 95.5%.ConclusionAlthough this particular model of TKA did not yield high‐flexion angles (ie, 140°) required for kneeling, squatting, or rising from the floor, significant clinical and radiographic gains were evident in these patients with RA.     

Freehand S2‐Alar‐Iliac Screw Placement Technique in Lumbosacral Spinal Tumors: A Preliminary Study

ObjectiveS2‐alar‐iliac (S2AI) screw technique is widely used in spinal surgery, but it is rarely seen in the field of spinal tumors. The aim of the study is to report the preliminary outcomes of the freehand S2AI screw fixation after lumbosaral tumor resection.MethodsThe records of patients with lumbosacral tumor who underwent S2AI screw fixation between November 2016 to November 2020 at our center were reviewed retrospectively. Outcome measures included operative time, blood loss, complications, accuracy of screws, screw breach, and overall survival. Mean ± standard deviation or range was used to present continuous variables. Kaplan–Meier curve was used to present postoperative survival.ResultsA total of 23 patients were identified in this study, including 12 males and 11 females, with an average age of 47.3 ± 14.5 (range,15–73). The mean operation time was 224.6 ± 54.1 (range, 155–370 min). The average estimated blood loss was 1560.9 ± 887.0 (600–4000 ml). A total of 46 S2AI screws were implanted by freehand technique. CT scans showed three (6.5%) screws had penetrated the iliac cortex, indicating 93.5% implantation accuracy rate. No complications of iatrogenic neurovascular or visceral structure were observed. The average follow‐up time was 31.6 ± 15.3 months (range, 13–60 months). Two patients'' postoperative plain radiography showed lucent zone around the screw. One patient underwent reoperation for wound delayed infection. At the latest follow‐up, eight patients had tumor‐free survival, 11 had survival with tumor, and four died of disease.ConclusionThe freehand S2AI screw technique is reproducible, safe, and reliable in the management of lumbosacral spinal tumors.     

Comparisons of the Efficacy and Safety of Total Knee Arthroplasty by Different Surgical Approaches: A Systematic Review and Network Meta‐analysis

The purpose of this network meta‐analysis was to investigate the efficacy and safety of total knee arthroplasty (TKA) considering seven different surgical approaches. Four databases (PubMed, Cochrane Library, EMBASE, Web of Science) were searched for clinical randomized controlled trials (RCTs) involving TKA with different surgical approaches. STATA 14.0 was used to construct network maps and publication bias graphs and conduct inconsistency tests, network meta‐analyses, and surface under the cumulative ranking (SUCRA) calculations. A total of 51 RCTs involving 4061 patients and 4179 knees from 18 countries were included. Among the seven surgical approaches, the midvastus approach (MV) was the top choice to reduce tourniquet use time, the subvastus approach (SV) had the shortest operation time, the mini‐midvastus approach (Mini‐SV) was associated with the least amount of time to achieve straight leg raise (SLR) after surgery, the mini‐medial parapatellar approach (Mini‐MP) reduced postoperative pain effects, and the medial parapatellar approach (MP) was the best approach to improve range of motion (ROM). Excluding the quadriceps‐sparing approach (QS), which was not compared, the use of the mini‐midvastus (Mini‐MV) may shorten the hospital stay. There were no significant differences in blood loss, postoperative complications, American Knee Society Score (AKSS) objective, or AKSS functional between the seven surgical approaches (P > 0.05).     

Effects of Platelet‐Rich Plasma and Bone Marrow Mesenchymal Stem Cells on Meniscal Repair in the White‐White Zone of the Meniscus

ObjectiveTo investigate the role of autologous platelet‐rich plasma (PRP) on the repair of meniscal white‐white zone injury through promoting the proliferation of canine bone marrow‐derived mesenchymal stem cells (BMSCs).MethodsA total of 24 beagle dogs were selected to construct meniscal white‐white zone injury models in both lateral knee joints. All subjects were divided into four groups: control, BMSCs, PRP, and PRP + BMSCs. Immunohistochemistry was applied in the expression detection of type I and type II collagens. HE staining and methylene blue staining were performed to observe the injury of cartilage of lateral femoral condyle in each group. ELISA was used to detect the osteopontin (OPN) content in cartilage of lateral femoral condyle. HE staining and magnetic resonance imaging (MRI) were used to observe the healing of meniscus in each group. Outcome measures include the expression of OPN in the synovial fluid of knee joint, the expression of type I collagen and type II collagen, the healing of meniscus injury, and the damage degree of lateral femoral condyle cartilage.ResultsCompared with the control group, the expressions of type I and type II collagens were enhanced in the PRP group and the PRP + BMSCs group. Compared with 1 week before modeling, the expression of OPN was elevated in the control group and the BMSCs group at 3 weeks after modeling. There were no significant differences in the above indicators between the PRP group and the PRP + BMSCs group. According to MRI and pathological section after HE staining, meniscal healing in the PRP group and the PRP + BMSCs group was significantly improved as compared to that of the control group and the BMSCs group (all P < 0.05), and there was no significant difference between the PRP group and the PRP + BMSCs group (P > 0.05). All subjects were divided into the non‐healing group and the healing group in accordance with the HE staining results in previous experiment. The injury of cartilage of lateral femoral condyle was significantly heavier in the non‐healing group than that in the healing group.ConclusionThe application of PRP alone or in combination with BMSCs could promote the clinical healing rate of meniscal white‐white zone injury.     

Combination of Intravenous and Intra‐Articular Application of Tranexamic Acid and Epsilon‐Aminocaproic Acid in Primary Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

ObjectiveThere were limited randomized controlled trials (RCTs) of epsilon‐aminocaproic acid (EACA) versus tranexamic acid (TXA) in total knee arthroplasty (TKA). The aim of the study was to compare the efficacy and safety of TXA and EACA in the combination of intravenous (IV) and intra‐articular (IA) administration on reducing blood loss in patients following primary TKA.MethodsFrom January 2020 to January 2021, a total of 181 patients undergoing a primary unilateral TKA were enrolled in this prospective randomized controlled trial. Patients in the TXA group (n = 90) received 20 mg/kg of intravenous TXA preoperatively, 1 g of intra‐articular TXA intraoperatively, and three doses of 20 mg/kg intravenous TXA at 0, 3, 6 h postoperatively. Patients in the EACA group (n = 91) received 120 mg/kg of intravenous EACA preoperatively, 2 g of intra‐articular EACA intraoperatively, and three doses of 40 mg/kg intravenous EACA at 0, 3, 6 h postoperatively. The primary outcomes were total blood loss (TBL), transfusion rates and drop of hemoglobin (HB) level. The secondary outcomes included postoperative hospital stays and postoperative complications. The chi‐square tests and Fisher''s exact tests were utilized to compare categorical variables, while the independent‐samples t‐tests and Mann–Whitney tests were used to compare continuous variables.ResultsThe patients who received TXA averaged less TBL than the patients who received EACA (831.83 ml vs 1065.49 ml, P = 0.015), and HB drop in TXA group was generally less than that of EACA group on postoperative day 1 and 3 (20.84 ± 9.48 g/L vs 24.99 ± 9.40 g/L, P = 0.004; 31.28 ± 11.19 vs 35.46 ± 12.26 g/L, P = 0.047). The length of postoperative stays in EACA group was 3.66 ± 0.81 day, which is longer than 2.62 ± 0.68 day in TXA group (P < 0.001). No transfusions were required in either group. The risk of nausea and vomiting in TXA group was significantly higher than that in EACA group (11/90 vs 0/91, P < 0.01).ConclusionAlthough the TBL and HB drop were slightly greater in EACA group, these results were not clinically important, given that no transfusions were required. EACA could be an alternative to TXA, especially for patients with severe nausea and vomiting after using TXA postoperatively. Further studies are needed to adjust dosage of EACA to make better comparison of the two drugs.     

治疗型关节炎护膝对实验性骨关节炎软骨细胞凋亡基因Bcl-2及p53的影响

目的：通过检测OA护膝对日本大耳白兔膝骨性关节炎软骨细胞凋亡基因Bcl-2、p53mRNA表达的影响,探讨OA护膝防治兔膝骨性关节炎软骨细胞凋亡的分子生物学机制。方法：健康6月龄日本大耳白兔54只,雌雄各半,空腹体重2～2．2kg,采用改良Huhh法复制膝骨性关节炎模型,随机分为6组,即正常组、模型组、对照组（微波组）、实验1组（电组）、实验2组（热组）、实验3组（护膝组）．正常组10只,常规饲养;模型组9只,造模后常规饲养;对照组9只,微波仪治疗30min,每日1次;实验1组9只,电（疏密波）治疗30min,每日1次;实验2组8只,热（热软膜）治疗30min,每日1次;实验3组9只,电热（OA护膝）治疗30min,每日1次,连续治疗16周时处死。采用荧光定量RT—PCR法检测各组膝关节软骨细胞Bcl-2、p53mRNA的表达水平。结果：16周时,各组所有抽提的兔关节软骨组织总RNA的OD260／OD280值均在1．80～2．00范围内,表明RNA纯度高：模型组、对照组、实验1组、实验2纽、实验3组关节软骨细胞p53的mRNA相对呈高表达,而关节软骨细胞Bcl-2的mRNA相对低表达,与正常组差异有统计学意义（P〈0．01）：关节软骨细胞Bcl-2、p53的mRNA相对表达水平,对照组、实验1组、实验2组、实验3组与模型组差异有统计学意义（P〈0．01）;对照组、实验1组、实验2组与实验3组差异有统计学意义（P〈0．01）。结论：OA护膝能提高关节软骨细胞Bcl-2 mRNA表达,减弱软骨细胞p53mRNA表达,从而抑制软骨细胞凋亡,延缓膝关节软骨的退变：     

Role of D‐dimer and Fibrinogen in the Diagnosis of Periprosthetic Joint Infection: A Systematic Review and Meta‐Analysis

The diagnostic potential of D‐dimer and fibrinogen to detect periprosthetic joint infection (PJI) of the hip and knee is not well‐understood. The aim of this study was to determine whether D‐Dimer and fibrinogen can be used as effective biomarkers to screen PJI. A systematic review of the literature indexed in Web of Science, PubMed, Cochrane Library, Embase, and Google Scholar databases was performed. All studies using D‐dimer levels in serum or plasma, or fibrinogen levels in plasma, for the diagnosis of PJI were included. Meta‐analysis estimates, including sensitivity, specificity, diagnostic odds ratios (DOR), and the area under the summary receiver operating characteristic curve (AUSROC), were calculated using a random‐effects model, and used to assess the diagnostic accuracy of these biomarkers. A total of nine studies were analyzed, and their quality was considered to be acceptable. D‐dimer gave a limited diagnostic value if serum and plasma combined: sensitivity (0.77, 95% confidence interval [CI] [0.63 to 0.87]), specificity (0.67, 95% CI [0.54 to 0.78]), DOR (6.81, 95% CI [2.67 to 17.37]), and AUSROC (0.78, 95% CI [0.74 to 0.82]). Plasma D‐dimer levels were associated with less satisfactory sensitivity (0.65, 95% CI 0.57 to 0.71), specificity (0.58, 95% CI 0.50 to 0.66), DOR (2.52, 95% CI 1.64 to 3.90), and AUSROC (0.65, 95% CI 0.61 to 0.69). Serum D‐dimer levels showed higher corresponding values of 0.89 (95% CI 0.79 to 0.94), 0.76 (95% CI 0.55 to 0.89), 24.24 (95% CI 10.07 to 58.32), and 0.91 (95% CI 0.88 to 0.93). Plasma fibrinogen showed acceptable corresponding values of 0.79 (95% CI 0.70 to 0.85), 0.73 (95% CI 0.57 to 0.85), 10.14 (95% CI 6.16 to 16.70), and 0.83 (95% CI 0.79 to 0.86). Serum D‐dimer may be an effective marker for the diagnosis of PJI in hip and knee arthroplasty patients, and it may show higher diagnostic potential than plasma fibrinogen. Plasma D‐dimer may have limited diagnostic potential.     

A multi‐country cross‐sectional study to assess predictors of daily versus on‐demand oral pre‐exposure prophylaxis in youth from South Africa,Uganda and Zimbabwe

IntroductionSub‐Saharan Africa (SSA) carries the burden of the HIV epidemic, especially among adolescents and young people (AYP). Little is known about pre‐exposure prophylaxis (PrEP) uptake and preferences among AYP in SSA. We describe preferences for daily and on‐demand PrEP among AYP in South Africa, Uganda and Zimbabwe.MethodsA cross‐sectional survey was conducted in 2019 among 13‐ to 24‐year olds, capturing socio‐demographics, HIV risk behaviours and preferences for daily or on‐demand PrEP. Logistic regression models were used to estimate odds ratios, adjusting for site, sex and age.Results and discussionA total of 1330 participants from Cape Town (n = 239), Johannesburg (n = 200), Entebbe (n = 491) and Chitungwiza (n = 400) were enrolled; 673 (51%) were male, and the median age was 19 years (interquartile range 17–22 years). Of 1287 participants expressing a preference, 60% indicated a preference for on‐demand PrEP with differences by site (p < 0.001), sex (p < 0.001) and age group (p = 0.003). On‐demand PrEP was most preferred in Entebbe (75%), among males (65%) versus females (54%) and in older participants (62% in 18‐ to 24‐year‐olds vs. 47% in 13‐ to 15‐year‐olds). After adjusting for site, sex and age group, preference for on‐demand PrEP decreased as sex frequency over the past month increased (p‐trend = 0.004) and varied with the number of partners in the last 6 months, being least popular among those reporting four or more partners (p = 0.02). Participants knowing further in advance that they were likely to have sex were more likely to prefer on‐demand PrEP (p‐trend = 0.02). Participants having a larger age gap with their most recent partner and participants whose last partner was a transactional sex partner or client were both less likely to prefer on‐demand compared to daily PrEP (p = 0.05 and p = 0.09, respectively). Participants who knew their most recent partner was living with HIV or who did not know the HIV status of their most recent partner were less likely to prefer on‐demand PrEP (p = 0.05).ConclusionsOur data show that AYP in four SSA communities prefer on‐demand over daily PrEP options, with differences seen by site, age and sex. PrEP demand creation needs to be reviewed, optimized and tailored to socio‐demographic differences and designed in conjunction with AYP.