Background Many patients undergoing TKA have both knee and ankle pathology, and it seems likely that some compensatory changes occur at each joint in response to deformity at the other. However, it is not fully understood how the foot and ankle compensate for a given varus or valgus deformity of the knee. Questions/purposes (1) What is the compensatory hindfoot alignment in patients with end-stage osteoarthritis who undergo total knee arthroplasty (TKA)? (2) Where in the hindfoot does the compensation occur? Methods Between January 1, 2005, and December 31, 2009, one surgeon (JJC) obtained full-length radiographs on all patients undergoing primary TKA (N = 518) as part of routine practice; patients were analyzed for the current study and after meeting inclusion criteria, a total of 401 knees in 324 patients were reviewed for this analysis. Preoperative standing long-leg AP radiographs and Saltzman hindfoot views were analyzed for the following measurements: mechanical axis angle, Saltzman hindfoot alignment and angle, anatomic lateral distal tibial angle, and the ankle line convergence angle. Statistical analysis included two-tailed Pearson correlations and linear regression models. Intraobserver and interobserver intraclass coefficients for the measurements considered were evaluated and all were excellent (in excess of 0.8).Results As the mechanical axis angle becomes either more varus or valgus, the hindfoot will subsequently orient in more valgus or varus position, respectively. For every degree increase in the valgus mechanical axis angle, the hindfoot shifts into varus by À0.43°(95% confidence interval [CI], À0.76°to À0.1°; r = À0.302, p = 0.0012). For every degree increase in the varus mechanical axis angle, the hindfoot shifts into valgus by À0.49°(95% CI, À0.67°to À0.31°; r = À0.347, p \ 0.0001). In addition, the subtalar joint had a strong positive correlation (r = 0.848, r 2 = 0.72, p \ 0.0001) with the Saltzman hindfoot angle, whereas the anatomic lateral distal tibial One of the authors certifies that he (AA) has or may receive payments or benefits, during the study period an amount USD 100,000 to USD 1,000,000 from Arthrex (Naples, FL, USA), an amount less than USD 10,000 from Arthrosurface (Franklin, MA, USA), and an amount USD 100,000 to USD 1,000,000 from MTP Solutions (Logan, UT, USA). One of the authors certifies that he (JJC) has or may receive payments or benefits, during the study period an amount more than USD 1,000,001 from DePuy (Warsaw, IN, USA) and an amount less than USD 10,000 from Lippincott Williams & Wilkins (Riverwoods, IL, USA). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Clinical Orthopaedics and Related Research 1 neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDAapproval status, of any drug or device prior to clinical use. Each aut...

Total hip arthroplasty (THA) is generally considered to be one of the most successful orthopedic surgical procedures. THA patients continue to experience symptoms, most commonly pain, which prevent their return to full function and activity. Possible causes include failure of fixation, instability and damage to soft tissues, associated with the trauma of the surgical procedure. Choosing the optimal surgical approach can minimize these risks and therefore improve the outcome of THA. Surgical approaches in THA include anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones)], posterior (posterolateral and posterior) and posterior-2 techniques. However, there is no current consensus regarding which approach is the most suitable. Therefore, we conducted a systematic review and network meta-analysis to compare the postoperative outcomes and complications among THA approach and identify which approach is the best for THA. We searched all RCT studies that compared intra-operative and postoperative outcomes of anterior, lateral [anterolateral (Hardinge) and direct lateral (Watson-Jones)], posterior (posterolateral and posterior) and posterior-2 approaches for THA from the PubMed and Scopus databases up to February 1, 2017. Data were independently extracted by two reviewers. A network meta-analysis was applied to assess treatment outcomes. Probability of being the best treatment was estimated using surface under the cumulative ranking curves (SUCRA). Fourteen RCTs (N = 1017 patients) met inclusion criteria. Interventions were anterior (N = 233 patients), lateral (N = 334 patients), posterior (N = 405 patients) and posterior-2 (N = 45 patients) approaches. A network meta-analysis showed that effects of anterior approach were higher to lateral, posterior and posterior-2 approaches with the pooled mean postoperative within 1 month and last follow-up of HHS of 2.56 (95% CI - 0.79, 5.91), 4.80 (95% CI 1.33, 8.26), 10.80 (95% CI 2.10, 19.49) and 6.40 (95% CI 0.72, 12.09), 2.22 (95% CI - 3.21, 7.66), 4.22 (95% CI - 6.81, 15.25), respectively. For VAS, lateral approach was lower to anterior, posterior and posterior-2 approaches. In terms of complication, posterior approach was the lowest risk with RR of 0.39 (95% CI 0.19, 0.81), 0.57 (95% CI 0.21, 1.57) and 1.74 (95% CI 0.36, 8.33) when compared to anterior, followed by lateral and posterior-2 approaches. Results of SUCRA indicated anterior and lateral approaches were the first and second ranks for postoperative HHS and VAS score, while posterior and lateral approaches were the first and second ranks for postoperative complications. We recommended using lateral approach that has an acceptable postoperative pain, function and complications (second rank for all outcomes) as a surgical technique for THA.

BackgroundRecently, a number of studies using intra-articular application of tranexamic acid (IA-TXA), with different dosage and techniques, successfully reduced postoperative blood loss in total knee replacement (TKR). However, best of our knowledge, the very low dose of IA-TXA with drain clamping technique in conventional TKR has not been yet studied. This study aimed to evaluate the effectiveness and dose-response effect of two low-dose IA-TXA regimens in conventional TKR on blood loss and blood transfusion reduction.MethodsBetween 2010 and 2011, a triple-blinded randomized controlled study was conducted in 135 patients undergoing conventional TKR. The patients were allocated into three groups according to intra-articular solution received: Control group (physiologic saline), TXA-250 group (TXA 250 mg), and TXA-500 group (TXA 500 mg). The solution was injected after wound closure followed by drain clamping for 2 hours. Blood loss and transfusion were recorded. Duplex ultrasound was performed. Functional outcome and complication were followed for one year.ResultsThere were forty-five patients per groups. The mean total hemoglobin loss was 2.9 g/dL in control group compared with 2.2 g/dL in both TXA groups (p > 0.001). Ten patients (22%, control), six patients (13%, TXA-250) and none (TXA-500) required transfusion (p = 0.005). Thromboembolic events were detected in 7 patients (4 controls, 1 TXA-250, and 2 TXA-500). Functional outcome was non-significant difference between groups.ConclusionsCombined low-dose IA-TXA, as 500 mg, with 2-hour clamp drain is effective for reducing postoperative blood loss and transfusion in conventional TKR without significant difference in postoperative knee function or complication.Trial registrationClinicalTrials.gov NCT01850394.

Introduction. The Infrapatellar fat pad (IPFP) represents an emerging alternative source of adipose-derived mesenchymal stem cells (ASCs). We compared the characteristics and differentiation capacity of ASCs isolated from IPFP and SC. Materials and Methods. ASCs were harvested from either IPFP or SC. IPFPs were collected from patients undergoing total knee arthroplasty (TKA), whereas subcutaneous tissues were collected from patients undergoing lipoaspiration. Immunophenotypes of surface antigens were evaluated. Their ability to form colony-forming units (CFUs) and their differentiation potential were determined. The ASCs karyotype was evaluated. Results. There was no difference in the number of CFUs and size of CFUs between IPFP and SC sources. ASCs isolated from both sources had a normal karyotype. The mesenchymal stem cells (MSCs) markers on flow cytometry was equivalent. IPFP-ASCs demonstrated significantly higher expression of SOX-9 and RUNX-2 over ASCs isolated from SC (6.19 ± 5.56-, 0.47 ± 0.62-fold; p value = 0.047, and 17.33 ± 10.80-, 1.56 ± 1.31-fold; p value = 0.030, resp.). Discussion and Conclusion. CFU assay of IPFP-ASCs and SC-ASCs harvested by lipoaspiration technique was equivalent. The expression of key chondrogenic and osteogenic genes was increased in cells isolated from IPFP. IPFP should be considered a high quality alternative source of ASCs.

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Background Periprosthetic joint infection (PJI) remains challenging since a “gold standard” for diagnosis has not yet been established. This study aimed to evaluate the accuracy of synovial fluid procalcitonin (SF-PCT) and serum procalcitonin as a diagnostic biomarker for PJI and to compare its accuracy against standard methods. Methods A prospective cohort study was conducted during 2015–2017 in 32 patients with painful hip or knee arthroplasty who have underwent revision surgery. Relevant clinical and laboratory data were collected. PJI was diagnosed based on the 2013 international consensus criteria. Preoperative blood sample and intraoperatively acquired joint fluid were taken for PCT measurement with a standard assay. Diagnostic accuracy was analyzed by the receiver-operating characteristic curve and the area under the curve (AUC). Results Twenty patients (62.5%) were classified as the PJI group, and 12 (37.5%) were classified as the aseptic loosening group. The median age was 68 years (range 38–87 years). The median values of SF-PCT and serum PCT in the PJI group were both significantly higher than those in the aseptic loosening group: the median serum PCT levels (interquartile range: IQR) were 0.33 ng/mL (0.08-2.79 ng/mL) in the PJI group compared with 0.04 ng/mL (0.03-0.06 ng/mL), and the median SF-PCT levels (IQR) were 0.16 ng/mL (0.12-0.26 ng/mL) in PJI group compared with 0.00 (0.00-0.00 ng/mL) (p < 0.001, both). SF-PCT, with a cut-off level of 0.08 ng/mL, had an AUC of 0.87, a sensitivity of 90.0%, a specificity of 83.3%, and a negative likelihood ratio (LR-) of 0.12. Serum PCT, with a standard cut-off level of 0.5 ng/mL, had an AUC of 0.70, a sensitivity of 40.0%, a specificity of 100.0%, and a LR- of 0.60. Conclusion SF-PCT appears to be a reliable test and could be useful as an alternative indicator or in combination with standard methods for diagnosing PJI.

Introduction: Postoperative outcomes in the elderly patients with intertrochanteric fracture were generally poor with a low rate of return to prefracture ambulatory level (RPAL). Recent studies showed that proximal femoral nail antirotation (PFNA) with cement augmentation might be useful for postoperative functional recovery. This study aimed to compare the outcomes in elderly patients with high surgical risk, American Society of Anesthesiologist (ASA) grade 3 or 4, who sustained intertrochanteric fractures and were treated with PFNA with and without cement augmentation, and to correlate perioperative surgical factors with the RPAL. Methods: A retrospective consecutive series was conducted based on 135 patients with prefracture ambulation classified as independent in community with or without a single cane (68 in augmented group and 67 in control group). Perioperative data and data on the complications within 1-year postsurgery were collected and compared. Predictive factors for RPAL were analyzed via logistic regression analysis. Results: The overall 1-year postoperative mortality rate was 10% (n = 14) with no significant difference between groups ( P = .273). The proportion of elderly patients with RPAL in the augmented group was significantly higher than for those in the control group (48% vs 29%, P = .043). Via univariate analysis, ASA grade 4 ( P = .077), history of stroke ( P = .035), and use of cement augmentation ( P = .041) were correlated with RPAL. However, multivariate regression analysis showed that ASA grade 4 (odds ratio [OR] = 0.40, 95% confidence interval [CI]: 0.18-0.90, P = .026) and use of cement augmentation (OR = 2.72, 95% CI: 1.22-6.05, P = .014) were the significant predictors for RPAL. Discussion and Conclusions: The results of the present study showed that PFNA with cement augmentation is safe and effectiveness in the intertrochanteric fracture treatment of elderly. Postoperative functional recovery, like RPAL, in elderly patients who sustained intertrochanteric fractures is relatively low, especially in those with ASA grade 4. However, cement augmentation with PFNA might be helpful for increasing the RPAL in high-surgical-risk geriatric patients.

The analysis of the sagittal balance is important for the understanding of the lumbopelvic biomechanics. Results from previous studies documented the correlation between sacro-pelvic orientation and lumbar lordosis and a uniqueness of spino-pelvic alignment in an individual person. This study was subjected to determine the lumbopelvic orientation using pelvic radius measurement technique. The standing lateral radiographs in a standardized standing position were taken from 100 healthy volunteers. The measurements which included hip axis (HA), pelvic radius (PR), pelvic angle (PA), pelvic morphology (PR-S1), sacral translation distance (HA-S1), total lumbosacral lordosis (T12-S1), total lumbopelvic lordosis (PR-T12) and regional lumbopelvic lordosis angles (PR-L2, PR-L4 and PR-L5) were carried out with two independent observers. The relationships between the parameters were as follows. PR-S1 demonstrated positive correlation to regional lumbopelvic lordosis and revealed negative correlation to T12-S1. PA showed negative correlation to PR-S1 and regional lumbopelvic lordosis, but revealed positive correlation to HA-S1. T12-S1 was significantly increased when PR-S1 was lesser than average (35°-45°) and was significantly decreased when PR-S1 was above the average. PR-L4 and PR-L5 were significantly reduced when PR-S1 was smaller than average and only PR-L5 was significantly increased when PR-S1 was above the average. In conclusion, this present study supports that lumbar spine and pelvis work together in order to maintain lumbopelvic balance.