Short-Term (6 Months or Less) Pain in Cemented versus Cementless Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: Cementless total knee arthroplasty (TKA) has increased in popularity to potentially improve survivorship. Radiostereometric studies demonstrate increased component migration during the first 3 to 6 months in cementless constructs, generating concern for increased postoperative pain during early osseointegration. The purpose of this study was to evaluate short-term (≤ 6 months) pain and function in cemented versus cementless TKA. We hypothesized that cementless TKA patients report increased pain during the short-term (≤ 6 months) postoperative period. METHODS: The MEDLINE, EMBASE, CINAHL, and Cochrane Libraries were searched for studies evaluating short-term (≤ 6 months) outcomes of cemented versus cementless primary TKA. Studies involving hybrid fixation were excluded. A meta-analysis was performed using standardized mean difference for primary outcomes (early postoperative pain) and weighted mean difference (WMD) for secondary outcomes (early postoperative function). RESULTS: There were eleven studies included. There was no significant difference in acute postoperative pain between cemented and cementless TKA within 6 months of index TKA (standardized mean difference 0.08 in favor of cemented TKA; P = .10). Early postoperative forgotten joint scores (WMD 0.81; P = .81) and knee injury and osteoarthritis outcome scores for joint replacement (WMD 0.80 in favor of cemented TKA; P = .14) were also similar between groups. CONCLUSIONS: There is no difference in short-term (≤ 6 months) pain or early function between patients receiving cemented and cementless TKA. This suggests that surgeons may utilize cementless TKA without fear of increased pain due to micromotion within 6 months of index arthroplasty. However, additional studies with uniform assessment methods are needed to further inform differences in short-term pain and early functional outcomes between cemented and cementless TKA.

Variation in practice for preoperative antibiotic prophylaxis: a survey from an academic tertiary referral center in the United States.

BACKGROUND: Antibiotic surgical prophylaxis is a core strategy for prevention of surgical site infections (SSI). Despite best practice guidelines and known efficacy of antibiotic prophylaxis in decreasing SSI risk, there is often wide variation in its use. This study was designed to determine the individual perspectives of perioperative providers at an academic tertiary referral center regarding their knowledge of preoperative antibiotic choice, dosing, and timing. METHODS: A prospective survey was conducted amongst surgical and anesthesia team members involved in preoperative antibiotic decision making. The survey addressed ten key principles relating to preoperative antibiotic use, including antibiotic choice, timing and rate of infusion, and dosing. The survey was distributed among orthopaedic surgeons, residents, and anesthesia providers at their respective monthly service line meetings between August 2017 to June 2019. The data was stored and analyzed in a Microsoft Excel worksheet. RESULTS: A total of 73 providers completed the survey. Twenty-two (30 %) of the providers agreed and 47 (64 %) disagreed that both vancomycin and cefazolin are equally effective for antibiotic prophylaxis. As for antibiotic choice in patients with penicillin allergies, 37 (51 %) agreed with vancomycin, 21 (29 %) agreed with clindamycin, and 15 (21 %) disagreed with both alternatives. When providers were surveyed regarding the appropriateness of standard versus weight adjusted dosing, 67 (92 %) agreed that vancomycin should be weight adjusted and 63 (86 %) agreed that cefazolin should be weight adjusted. CONCLUSIONS: There is no clear consensus amongst providers for which antibiotic to administer for antibiotic prophylaxis despite existing guidelines. Discrepancy also exists between orthopaedic surgery and anesthesia providers in regards to appropriate antibiotic choice for patients with reported penicillin allergies. Institutions should implement evidence-based protocols for preoperative antibiotic prophylaxis and continue to prospectively monitor compliance in order to identify any inconsistencies that could result in inappropriate antibiotic prophylaxis for patients.

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

BACKGROUND: Persistent 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. METHODS: MEDLINE, 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. RESULTS: SSI 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). CONCLUSION: ciNPWT 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.

Implantable Subacromial Balloon Spacers in Patients With Massive Irreparable Rotator Cuff Tears: A Systematic Review of Clinical, Biomechanical, and Financial Implications.

PURPOSE: To determine the clinical, biomechanical, and financial impact of the use of subacromial balloon spacers in the surgical management of massive, irreparable rotator cuff tears (RCTs). METHODS: All studies assessing the use of implantable subacromial balloon spacers for management of massive, irreparable RCTs were systematically searched. Risk of bias was assessed using Methodological Index for Non-Randomized Studies criteria. Data extraction and analysis was performed for pain and function scores, shoulder range of motion (ROM), glenohumeral contact pressure and vertical migration of humeral head, and cost. Subjective synthesis was performed with forest plots when outcomes were reported in 3 or more studies. RESULTS: In total, 19 studies met inclusion criteria for analysis; 337 patients (mean age 68 years) had 343 subacromial balloon spacer implantations. Throughout a mean follow-up of 33 months, there was significant improvement in the Total Constant Score (preoperative: 22.5-41.8; postoperative: 51.4-72.3), Oxford Shoulder Score (preoperative: 21.3-26; postoperative: 34.39-48.2), American Shoulder and Elbow Surgeons score (preoperative: 24.5-59.1; postoperative: 72.5-85.7), and shoulder ROM parameters. Subacromial balloon spacer placement resisted superior humeral head migration (range of preoperative to postoperative difference: 2.8-6.2 mm) and decreased peak subacromial pressure during shoulder ROM. CONCLUSIONS: Existing literature of subacromial balloon spacers has a high risk of bias, lack of appropriate control, and low levels of evidence. A qualitative synthesis indicates that subacromial balloon spacer implantation in patients with massive irreparable RCTs is cost-effective and leads to improved function (Total Constant Score and Oxford Shoulder Score) and ROM. In cadaveric studies, subacromial balloon spacers resist superior humeral head migration and reduce subacromial pressure. The theoretical risk of biodegradation of the balloon spacer has not been substantiated in study of up to 5-years follow-up, and the risk of complications from this procedure appears to be minimal. LEVEL OF EVIDENCE: IV; Systematic review of level III-IV studies.

Superior gluteal artery pseudoaneurysm following intramedullary nailing of an atypical femoral fracture.

A 79-year-old woman with a history of osteoporosis treated with alendronate presented to the orthopaedic clinic with persistent left hip pain. X-ray and bone scan revealed an atypical femoral fracture associated with bisphosphonate use. The fracture was repaired with antegrade femoral intramedullary fixation. Her postoperative course was complicated by acute blood loss anaemia requiring several packed red blood cell transfusions and progressive thigh ecchymosis. CT angiography demonstrated extravasation of contrast from the superior gluteal artery (SGA). Subsequent angiography revealed an SGA pseudoaneurysm above the intramedullary nail, which was coil embolised. Iatrogenic SGA injury secondary to femoral intramedullary fixation is a rare complication, with only one previous case reported in the literature. Therefore, successful identification of the injury required attention to patient reported symptoms, neurovascular examinations and laboratory values to determine the cause of the patient's postoperative anaemia. The patient made a full recovery and did not have any long-term adverse effects following the embolisation.

BPTF inhibits NK cell activity and the abundance of natural cytotoxicity receptor co-ligands.

Using syngeneic BALB/c mouse breast cancer models, we show that the chromatin remodeling subunit bromodomain PHD finger transcription factor (BPTF) suppresses natural killer (NK) cell antitumor activity in the tumor microenvironment (TME). In culture, BPTF suppresses direct natural cytotoxicity receptor (NCR) mediated NK cell cytolytic activity to mouse and human cancer cell lines, demonstrating conserved functions. Blocking mouse NCR1 in vivo rescues BPTF KD tumor weights, demonstrating its importance for the control of tumor growth. We discovered that BPTF occupies heparanase (Hpse) regulatory elements, activating its expression. Increased heparanase activity results in reduced cell surface abundance of the NCR co-ligands: heparan sulfate proteoglycans (HSPGs). Using gain and loss of function approaches we show that elevated heparanase levels suppress NK cell cytolytic activity to tumor cells in culture. These results suggest that BPTF activates heparanase expression, which in turn reduces cell surface HSPGs and NCR co-ligands, inhibiting NK cell activity. Furthermore, gene expression data from human breast cancer tumors shows that elevated BPTF expression correlates with reduced antitumor immune cell signatures, supporting conserved roles for BPTF in suppressing antitumor immunity. Conditional BPTF depletion in established mouse breast tumors enhances antitumor immunity, suggesting that inhibiting BPTF could provide a novel immunotherapy.