Background Minimally anterolateral approach (MAA) and direct anterior approach (DAA) have been reported as beneficial for total hip arthroplasty (THA) due to their ability to reduce postoperative pain and lead to quicker rehabilitation by preserving muscle insertions. As there is an ongoing debate on the effect of these two approaches on early postoperative outcomes, this prospective study aimed to assess the difference in early clinical, radiological, and patient-reported outcomes between the two minimally invasive approaches. Methods A total of 98 patients, 50 in the MAA group and 48 in the DAA group, were included in the study. Patients with complete data were evaluated preoperatively and postoperatively at 2, 6, and 12 weeks. Clinical measurements, including the ability to climb stairs and walk, 6-min walk test (6MWT), the Forgotten Joint Scale (FJS-12), Japanese Orthopedic Association (JOA) Hip scores, radiological evaluation, and complications were analyzed. Results There were no significant differences in clinical outcomes and implant alignments between MAA and DAA groups. In regards to patient-reported outcomes, the FJS-12 was significantly higher in the MAA group compared to group DAA at 2 and 6 weeks postoperatively. However, there was no significant difference in the FJS-12 between the two groups 12 weeks after surgery. The differences also included shorter operative times (62.4 ± 9.05 min vs. 71 ± 8.01 min), less blood loss (132.6 ± 43.31 ml vs. 159.23 ± 37.25 ml), lower Hb drop (29.56 ± 8.02 g/L vs. 36.4 ± 7.12 g/L), and fewer blood transfusions in the MAA group (4.0% vs. 18.8%). The incidence of the lateral femoral cutaneous nerve (LFCN) neuropraxia after surgery was 7 (14.6%) in the DAA group and 0 in the MAA group. One fracture was found in each group and managed conservatively. Conclusion MAA and DAA approach yielded excellent and similar early clinical outcomes. However, better patient-reported outcomes could be achieved by MAA THA. The MAA resulted in a safer approach associated with shorter operative times, less blood loss, lower Hb drop, fewer blood transfusions, and LFCN neuropraxia than DAA. A longer follow-up is needed to further examine differences between these procedures.

Background: Traumatic obturator dislocation of the hip joint associated with greater trochanter fracture is a rare injury. We used the lateral approach through the rectus abdominis to remove the femoral head dislocated into the obturator, and the posterolateral approach was used for reduction and internal fixation of the femoral greater trochanteric fracture and total hip replacement (THR). Good follow-up results were achieved. To the best of our knowledge, this is the first report on this particular type of injury and on this approach to treating this type of injury. Case Report: The patient was hospitalized due to a traffic accident that resulted in the patient experiencing swelling and deformity accompanied by limited mobility of the left hip and left knee. X-ray examination and CT confirmed that the patient suffered from left hip obturator dislocation, greater trochanter fracture, pelvic fracture (Tile B), left acetabular fracture, right open tibiofibular comminuted fracture (Gustilo III), and posterior urethral injury. The femoral head was removed from the pelvic cavity through a pararectus approach under general anesthesia. A posterolateral approach was used for open reduction, and cable internal fixation for the left intertrochanteric fracture and uncemented THR were performed. Results: The ability to work was restored 6 months after the operation. The Harris hip score, reflecting joint function, was 86 points after 2 years of follow-up observation. Conclusion: A lateral approach of rectus abdominis to remove the dislocated femoral head in the pelvis from the obturator should be selected, along with the posterolateral approach for reduction and internal fixation of the intertrochanteric fracture and THR. This case also provides a new reference for the treatment of this type of hip fracture dislocation.

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

Purpose To retrospectively review the early- and medium-term clinical outcomes of lateral capsulorrhaphy by medial synovial flap transposition in total knee arthroplasty for the treatment of knee osteoarthritis with permanent dislocation of the patella. Method To surgically restore the patellar trajectory in 29 patients with knee osteoarthritis associated with permanent patellar dislocation undergoing total knee arthroplasty using medial synovial flap transposition to repair the lateral joint capsule. Preoperative and 2-year postoperative conditions and knee mobility were compared using the American Knee Society score function score, UCLA activity scale score, and visual analogue (VAS) pain scores. The patients were examined radiographically for full-length knee and axial patellar reduction while standing on both lower limbs. Result The patients' American Knee Society function scores improved from 40.2 ± 12.1 preoperatively to 80.5 ± 7.3 at 2 years postoperatively (P < 0.001), and their UCLA activity class scores improved from 3.9 ± 0.6 preoperatively to 6.8 ± 0.7 at 2 years postoperatively (P < 0.001). VAS pain scores decreased from 41.8 ± 6.0 points preoperatively to 10.1 ± 3.7 at two years postoperatively (P < 0.001). Knee mobility improved from 74.6 ± 8.9 degrees preoperatively to 110.5 ± 4.5 degrees at two years postoperatively (P < 0.001), and imaging showed no signs of subluxation or dislocation of the patella in any of the patients. Conclusions The correction of the patellar trajectory in patients with osteoarthritis with permanent patellar dislocation undergoing total knee arthroplasty using medial synovial flap transposition to repair the lateral joint capsule can lead to satisfactory early and medium-term clinical results.

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Background Both of Minimally Anterolateral Approach (MIS-ALA) and Direct Anterior Approach (DAA) have been reported to be advantageous in Total Hip Arthroplasty (THA), reducing postoperative pain and permit quicker rehabilitation by preserving muscle insertions. There is little literature concern the difference of them. Therefore, we conducted a prospective study to assess the difference of early clinical outcomes, radiological, and patient-reported outcomes between the two minimally invasive approaches of MIS-ALA and DAA. Methods The subjects were 98 patients, with 50 in the MIS-ALA group and 48 in the DAA group. Patients with complete data were evaluated preoperatively and postoperatively at 2, 6 and 12 weeks. Clinical measurements including the ability to climb stairs and walk, a 6 minutes walk test (6MWT) distances, the Forgotten Joint Scale (FJS-12), Japanese Orthopaedic Association (JOA) Hip scores, radiological evaluation, and complications data were collected. Results There were no significant differences in clinical outcomes and implant alignments between MIS-ALA and DAA groups. In regards to patient-reported outcomes, the FJS-12 was significantly higher in the MIS-ALA group than in the group DAA at 2 and 6 weeks postoperatively. However, there was no significant difference in the FJS-12 between the two groups at 12 weeks after surgery. The differences also included shorter operative times, less blood loss, lower Hb drop, and fewer blood transfusions in the MIS-ALA group. The incidence of lateral femoral cutaneous nerve (LFCN) neuropraxia after surgery was 7 (14.6%) in the DAA group, zero occurred in the MIS-ALA group. One fracture was identified with each group and managed conservatively. Conclusion Both MIS-ALA and DAA approaches yielded excellent and similar early clinical outcomes. However, better patient-reported outcomes could be achieved by MIS-ALA THA. The MIS-ALA was a safer approach for shorter operative times, less blood loss, lower Hb drop, fewer blood transfusions and LFCN neuropraxia compared with DAA. A longer follow-up is needed to examine differences between these procedures.

Purpose: To find the best short-term daily rhEPO-based treatment protocols for blood-saving purpose in THA.Method: The patients were randomized to 1 of 3 interventions: Patients in group A received 10,000 IU (150IU/kg) of subcutaneous rhEPO (1 ml) daily from 5 days preoperatively to 3 days postoperatively (9 doses in total); Patients in group B received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to 4 days preoperatively and then 10,000 IU (150IU/kg) of subcutaneous rhEPO daily till 3 days postoperatively (6 doses in total). Patients in group C received 1 ml of subcutaneous normal saline daily from 5 days preoperatively to one day preoperatively and then 10,000 IU (150IU/kg) of subcutaneous rhEPO daily from the day of surgery to 3 days postoperatively (4 doses in total). Results: 180 patients were included. On postoperative day one, patients in the group A showed significantly higher Hb level (108.4±11.4 g/L) than group B and C (107.8±8.4 and 103.9±8.8 g/L, respectively) (p<0.001), the Hb level in group B was also markedly higher than in group C (p=0.045). On postoperative day 3, no significant difference was found between group B and C in Hb level (98.7±10.5 and 94.9±8.7 g/L, respectively) (p=0.094), but the Hb level in group A (103.6±11.0 g/L) was still markedly higher than in group B and C. In terms of blood loss, no markedly difference was found in intraoperative blood loss among group A, B and C (78.3±22.4, 84.6±29.1, and 80.3±23.9 ml, respectively) (p=0.381), but on postoperative day one, the mean blood loss was significantly more in groups B and C (371.2±124.6, and 522.4±189.4 ml, respectively) than in group A (284.8±112.9 ml) (p<0.001), and group B had significantly less blood loss than group C (p<0.001). With respect to the total blood loss, group B and C had markedly more total blood loss (642.6±232.9, and 881.6±314.9 ml, respectively) than group A (514.5±204.6 ml) and group B had significantly less blood loss than group C (p<0.001) (Table 2). Only 2 patients in each group received allogeneic blood transfusion and each patient received 2 units of red blood cells, so, the transfusion requirements among the three groups were comparable.Conclusions: Daily small-dose of subcutaneous rhEPO administered from 5 days before THA could significantly decrease perioperative blood loss and improve postoperative Hb levels, without increasing risks of complications, when compared with the application of rhEPO from 3 days before THA or from the day of surgery. Therefore, we recommend the more practical and highly effective therapeutic regimen of small-dose of subcutaneous rhEPO daily from 5 days preoperatively to 3 days postoperatively for patients scheduled for THA.

Objective To investigate the effect of the first dose of tranexamic acid received intravenously before tourniquet compression and release in total knee arthroplasty (TKA) on perioperative blood loss and therapeutic efficacy of patients. Methods In this double-blind trial, 90 patients undergoing primary TKA were randomized into 2 groups: the patients in group A was received intravenous tranexamic acid (TXA) 10 minutes before tourniquet compression (20 mg/kg) and 3, 6 and 24 hours later (10 mg/kg), and the patients in Group B was treated the same as Group A but received intravenous TXA before tourniquet release. The primary outcomes were the change of blood loss, hemoglobin and hematocrit. Secondary outcomes included operation and tourniquet time, blood transfusion rate, subcutaneous petechiae and circumferential changes of the operated limb, visual analog scale (VAS), hospital for special surgery (HSS) score, length of stay (LOS) postoperatively, complications and patient satisfaction. Results No statistically significant differences were found between the 2 groups with regard to age, gender, weight, BMI, Kellgren-Lawrence class, preoperative blood volume, preoperative laboratory values, operation and tourniquet time, transfusion rate, knee circumference, preoperative HSS, VAS. There was no significant difference in intraoperative blood loss (IBL) (52.71 ml vs. 63.44 ml, P= 0.07), hidden blood loss (HBL) (91.39 ml vs. 119.90, P= 0.40) and total blood loss (TBL) (144.1 ml vs. 183.3 ml, P= 0.72) between groups A and B. Hemoglobin, hematocrit and red blood cell count (RBC) dropped to a low point on postoperative day 3 and then rebounded, returning to normal levels on day 21, and the trend of change between the 2 groups was no statistically significant difference. There was no significant difference in subcutaneous ecchymosis, knee swelling, HSS, VAS, LOS postoperatively, complication rate and patient satisfaction. Conclusion There was no significant difference in total perioperative blood loss, knee swelling, subcutaneous bruising and petechiae, knee function, complication rate and satisfaction between the intravenous tranexamic acid before tourniquet compression and release in primary total knee arthroplasty. However, the trend towards better reduction of perioperative blood loss, as reflected by changes in blood loss and h ematocrit, may be related to the role of the effective blood concentration formed in the operative area before tourniquet pressurization. Although it is not possible to conclude that better hemostasis can be achieved by administration before tourniquet compression, we believes that 10 minutes before tourniquet compression is a more recommendable option when conditions permit, and that the second postoperative dose should be dripped intravenously 3 hours after the first dose to ensure effective plasma concentrations.