不缝合腹膜剖宫产术式的临床观察

目的　探讨不缝合腹膜剖宫产术式的临床效果。方法　选取剖宫产不缝合腹膜 80例产妇作为观察组 ,与同期分娩按传统方法缝合腹膜产妇 80例作为对照组 ,观察两组术后病率、肠功能恢复及切口愈合情况。结果　观察组术后病 6例 ,对照组 15例 ,两组比较 ,差异有显著性 (P <0 0 5 ) ;观察组术后肛门排气时间为 2 0 5± 5 33h ,对照组为 36 6 7± 6 17h ,两组比较 ,差别有高度统计学意义 (P <0 0 1) ;腹部切口愈合两组无差异。结论　不缝合腹膜剖宫产术式安全、有效、并发症少 ,值得在临床上推广应用。     

葡萄籽提取物对四氯化碳诱导大鼠脂质过氧化反应的影响

目的 :研究葡萄籽提取物对四氯化碳 (CCl4 )引起的脂质过氧化反应和抗氧化能力的影响。方法 :通过对大鼠的体内实验 ,测定大鼠肝和脑组织中由 CCl4 诱导产生的过氧化脂质生成物丙二醛(MDA) (TBA法 )的含量、血清中的超氧化物歧化酶 (SOD) (比色法 )活性和血清中总抗氧化能力(T- AOC) (比色法 )。结果 :葡萄籽提取物可明显降低大鼠肝和脑组织中 MDA的生成量 ,明显升高血清中 SOD活性和 T- AOC。结论 :葡萄籽提取物具有明显的抗氧化作用。     

肉苁蓉总苷对~(60)Coγ射线损伤小鼠免疫功能的防护作用

目的　研究肉苁蓉总苷 (GCs)对 6 0 Co损伤小鼠免疫功能及 30 d存活率的影响。方法　小鼠在不同剂量6 0 Coγ射线照射前后 ,均服以 GCs,观察辐射及 GCs对其免疫功能的改变。结果　 6 0 Co照射剂量为 2 ,4及 7Gy时 ,可造成小鼠体液免疫、细胞免疫功能和非特异性免疫功能及 30 d存活率下降 (P<0 .0 5或 P<0 .0 1) ;GCs(31.2 5 ,6 2 .5 ,12 5 m g/ kg)组可促进上述各指标的恢复 ,对 6 0 Co损伤小鼠的抗体产生、外周血 T淋巴细胞数目、迟发型超敏反应、腹腔巨噬细胞的吞噬功能均有明显保护作用 (P<0 .0 1或 P<0 .0 5 ) ;且能提高受照小鼠的脾指数、胸腺指数及 30 d存活率 (P<0 .0 1或 P<0 .0 5 )。结论　 GCs对辐射损伤小鼠的免疫功能具有较强防护作用     

What is the Level of Evidence Substantiating Commercial Payers’ Coverage Policies for Total Joint Arthroplasty?

BackgroundThe prevalence of total joint arthroplasty (TJA) in the United States has drawn the attention of health care stakeholders. The payers have also used a variety of strategies to regulate the medical necessity of these procedures. The purpose of this study was to examine the level of evidence of the coverage policies being used by commercial payers in the United States.MethodsThe references of the coverage policies of four commercial insurance companies were reviewed for type of document, level of evidence, applicability to a TJA population, and success of nonoperative treatment in patients with severe degenerative joint disease.Results282 documents were reviewed. 45.8% were primary journal articles, 14.2% were level I or II, 41.2% were applicable to patients who were candidates for TJA, and 9.9% discussed the success of nonoperative treatment in patients who would be candidates for TJA.ConclusionMost of the references cited by commercial payers are of a lower level of scientific evidence and not applicable to patients considered to be candidates for TJA. This is relatively uniform across the reviewed payers. The dearth of high-quality literature cited by commercial payers reflects the lack of evidence and difficulty in conducting high level studies on the outcomes of nonoperative versus operative treatment for patients with severe, symptomatic osteoarthritis. Patients, surgeons, and payers would all benefit from such studies and we encourage professional societies to strive toward that end through multicenter collaboration.     

Diagnostic Utility of Platelet Count/Lymphocyte Count Ratio and Platelet Count/Mean Platelet Volume Ratio in Periprosthetic Joint Infection Following Total Knee Arthroplasty

BackgroundDiagnosing a periprosthetic joint infection (PJI) can be challenging and often requires a combination of clinical and laboratory findings. Monocyte/lymphocyte ratio, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio (PLR), and platelet/mean platelet volume ratio (PVR) are simple predictors for inflammation that can be readily obtained from complete blood count. The aim of this study is to evaluate the diagnostic utility of these markers in predicting PJI in total knee arthroplasty (TKA) patients.MethodsA total of 538 patients who underwent revision TKA with calculable marker ratios prerevision in 2 groups were evaluated: (1) 206 patients with a preoperative diagnosis of PJI (group I) and (2) 332 patients treated for revision TKA for aseptic failures (group II). The diagnostic abilities of the markers were assessed via receiver operator characteristic curve analysis.ResultsThe optimal threshold of PVR at 30.82 had the highest sensitivity of 87.7%, while the optimal threshold of PLR at 234.13 had the highest specificity of 82.5%. Both PLR and PVR, when combined with Musculoskeletal Infection Society thresholds for erythrocyte sedimentation rate, C-reactive protein, synovial WBC, and PMN%, achieve significantly higher sensitivity and specificity rates for PJI at or above 97% (PLR: 99.03%; 98.80%; PVR: 98.54%;97.89%).ConclusionOur study demonstrates that PVR and PLR, which are readily available and inexpensive to obtain from complete blood counts, when combined with serum and synovial fluid markers have increased sensitivity and specificity comparable to that of alpha defensin. This suggests that PVR and PLR can be used together with other hematologic and aspirate markers to increase the accuracy of PJI diagnosis in TKA patients.     

Biomechanical evaluation of total ankle arthroplasty. Part II: Influence of loading and fixation design on tibial bone–implant interaction

Finite element (FE) models to evaluate the burden placed on the interaction between total ankle arthroplasty (TAA) implants and the bone often rely on peak axial forces. However, the loading environment of the ankle is complex, and it is unclear whether peak axial forces represent a challenging scenario for the interaction between the implant and the bone. Our goal was to determine how the loads and the design of the fixation of the tibial component of TAA impact the interaction between the implant and the bone. To this end, we developed a framework that integrated robotic cadaveric simulations to determine the ankle kinematics, musculoskeletal models to determine the ankle joint loads, and FE models to evaluate the interaction between TAA and the bone. We compared the bone–implant micromotion and the risk of bone failure of three common fixation designs for the tibial component of TAA: spikes, a stem, and a keel. We found that the most critical conditions for the interaction between the implant and the bone were dependent on the specimen and the fixation design, but always involved submaximal forces and large moments. We also found that while the fixation design influenced the distribution and the peak value of bone–implant micromotion, the amount of bone at risk of failure was specimen dependent. To account for the most critical conditions for the interaction between the implant and the bone, our results support simulating multiple specimens under complex loading profiles that include multiaxial moments and span entire activity cycles.     

Closed Incision Negative Pressure Wound Therapy for Elective Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundPersistent wound drainage after total joint arthroplasty (TJA) increases the risk of surgical site infections (SSIs). Closed incision negative pressure wound therapy (ciNPWT) decreases infections in traumatic wounds, but evidence for its use after elective TJA is limited. The purpose of this meta-analysis of level I studies is to determine the effect of ciNPWT on risk of SSI and wound complications following TJA.MethodsMEDLINE, EMBASE, CINAHL, and Cochrane Library were searched for randomized controlled trials comparing ciNPWT vs standard dressings after total hip (THA) and total knee arthroplasty (TKA). Studies exclusively involving THA for femoral neck fractures were excluded. Risk of SSI and noninfectious wound complications (blisters, seroma, hematoma, persistent drainage, dehiscence, and wound edge necrosis) following TJA were analyzed.ResultsSSI risk was lower with ciNPWT compared to standard dressings (3.4% vs 7%; relative risk [RR] 0.48, P = .007), specifically in revision THA and TKA (4.1% vs 10.5%; RR 0.41, P = .03). ciNPWT increased the noninfectious complication risk after primary TKA (RR 4.71, P < .0001), especially causing wound blistering (RR 12.66, P < .0001). ciNPWT decreased hospital length of stay by 0.73 days (P = .04) and reoperation rate (RR 0.28, P = .01).ConclusionciNPWT decreases SSI risk compared to standard dressings after revision TJA, but not primary TJA. ciNPWT is associated with >12-fold increased risk of wound blistering after primary TKA. ciNPWT plays a role in revision TJA management, but additional randomized controlled trials with uniform wound assessment methods must be performed to sufficiently power findings and draw conclusions on the use of ciNPWT after primary TJA.     

Projected Economic Burden of Periprosthetic Joint Infection of the Hip and Knee in the United States

BackgroundIn addition to the significant morbidity and mortality associated with periprosthetic joint infection (PJI), the cost of treating PJI is substantial. Prior high-quality national estimates of the economic burden of PJI utilize data up to 2009 to project PJI growth in the United States through 2020. Now in the year 2020, it is appropriate to evaluate these past projections and incorporate the latest available data to better understand the current scale and burden of PJI in the United States.MethodsThe Nationwide Inpatient Sample (2002-2017) was used to identify rates and associated inpatient costs for primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) and PJI-related revision TKA and THA. Poisson regression was utilized to model past growth and project future rates and cost of PJI of the hip and knee.ResultsUsing the most recent data, the combined annual hospital costs related to PJI of the hip and knee were estimated to be $1.85 billion by 2030. This includes $753.4 million for THA PJI and $1.1 billion for TKA PJI, in that year. Increases in PJI costs are mainly attributable to increases in volume. Although the growth in incidence of primary THA and TKA has slowed in recent years, the incidence of PJI and the cost per case of PJI remained relatively constant from 2002 to 2017.DiscussionUnderstanding the current and potential future financial burden of PJI for surgeons, patients, and healthcare systems is essential. There is an urgent need for efficacious preventive strategies in reducing rates of PJI after THA and TKA.     

Early and Direct Rehab Transfer Leads to Significant Cost Savings and Decreased Hospital Length of Stay for Total Joint Arthroplasty in a Veteran Population

BackgroundTotal joint arthroplasty is the most common elective orthopedic procedure in the Veterans Affairs hospital system. In 2019, physical medicine and rehabilitation began screening patients before surgery to select candidates for direct transfer to acute rehab after surgery. The primary outcome of this study was to demonstrate that the accelerated program was successful in decreasing inpatient costs and length of stay (LOS). The secondary outcome was to show that there was no increase in complication, reoperation, and readmission rates.MethodsA retrospective review of total joint arthroplasty patients was conducted with three cohorts: 1) control (n = 193), 2) transfer to rehab orders on postop day #1 (n = 178), and 3) direct transfers to rehab (n = 173). To assess for demographic disparities between cohorts, multiple analysis of variance tests followed by a Bonferroni P-value correction were used. Differences between test groups regarding primary outcomes were assessed with analysis of variance tests followed by pairwise t-tests with Bonferroni P-value corrections.ResultsThere were no significant differences between the cohort demographics or comorbidities. The mean total LOS decreased from 7.0 days in the first cohort, to 6.9 in the second, and 6.0 in the third (P = .00034). The mean decrease in cost per patient was $14,006 between cohorts 1 and 3, equating to over $5.6 million in savings annually. There was no significant change in preintervention and postintervention short-term complications (P = .295).ConclusionsSignificant cost savings and decrease in total LOS was observed. In the current health care climate focused on value-based care, a similar intervention could be applied nationwide to improve Veterans Affair services.