Aspirin is as effective as low molecular weight heparins in preventing symptomatic venous thromboembolism following arthroscopic anterior cruciate ligament reconstruction.

OBJECTIVE: The optimal agent for thromboprophylaxis following arthroscopic anterior cruciate ligament reconstruction (ACLR) remains unclear, particularly in patients with a low baseline risk for venous thromboembolism (VTE). This retrospective cohort study aims to compare the effectiveness and safety of aspirin versus low molecular weight heparins (LMWHs) in this specific patient population. METHODS: We analyzed data from patients who underwent ACLR between March 2016 and March 2021, focusing on those with a low risk for VTE. High-risk individuals, identified by factors such as cardiac disease, pulmonary disease, diabetes mellitus, previous VTE, inflammatory bowel disease, active cancer, and a BMI > 40, were excluded (n = 33). Our approach included a thorough review of medical charts, surgical reports, and pre-operative assessments, complemented by telephone follow-up conducted over a 3-month period by a single investigator. We assessed the incidence of symptomatic VTE, including deep vein thrombosis and pulmonary thromboembolism, as the primary outcome. The secondary outcomes included to complications related to the surgery and thromboprophylaxis. Statistical analysis included descriptive statistics, univariate logistic regression models, and calculations of incidence rates. RESULT: In our study, 761 patients (761 knees) were included, with 458 (60.18%) receiving aspirin and 303 (39.82%) receiving LMWH. The two groups showed no significant differences in demographic factors except for age. The incidence of VTE was reported at 1.31% (10 individuals). Specifically, five patients in the aspirin group (1.09%) and five patients in the LMWH group (1.65%) developed a symptomatic VTE event (p = 0.53). Additionally, the two groups did not significantly differ in terms of other complications, such as hemarthrosis or surgical site infection (p > 0.05). Logistic regression analysis revealed no statistically significant difference in VTE risk between the two groups. CONCLUSION: This study, focusing on isolated ACLR in patients with a low baseline risk for venous thromboembolism, demonstrated that aspirin is equally effective as low molecular weight heparins for VTE prophylaxis following this surgery. LEVEL OF EVIDENCE: III.

Knee Flexion Deformity and Increased Posterior Tibial Slope Associated with Osgood Schlatter Disease: A Case Report and Review of Literature.

Genu recurvatum associated with Osgood-Schlatter disease (OSD) has been reported in several studies. In this report, we describe a rare complication of a case of OSD with flexion contracture (tfighat is the exact opposite of the knee deformity classically associated with OSD) and increased posterior tibial slope. In the current article, we report a 14-year-old case of OSD referred to our center with a fixed knee flexion contracture. Radiographic evaluation revealed a tibial slope of 25 degrees. There was no limb length discrepancy. Bracing that was prescribed in the primary center before referring to us was not successful in treating this deformity. He underwent anterior tibial tubercle epiphysiodesis surgery. After a year, the flexion contracture of the patient was significantly reduced. The tibial slope decreased by 12 degrees and reached 13 degrees. The present report suggests that OSD may affect the posterior tibial slope and lead to knee flexion contracture. Surgical epiphysiodesis can correct the deformity.

Using Blumensaat's line to determine the sagittal alignment of the distal femur.

BACKGROUND: A coherent measurement approach for sagittal alignment of the distal femur after fracture reduction or distal femur osteotomies is not available. The present study aims to introduce a new method using Blumensaat's line and tangent lines to the femoral cortexes to determine the sagittal alignment of the distal femur. METHODS: 113 patients who had true lateral knee radiographs were included. All of the radiographs were evaluated by one fellowship-trained knee surgeon and one radiologist using the PACS system. The Blumensaat's line was determined on the true lateral knee radiographs. Then, three long lines were drawn on the distal third of the femoral shaft. The first line is tangent to the anterior cortex of the femur, the second line is along with the anatomical axis of the femur, and the third line is tangent to the posterior cortex of the femur. The angles between Blumensaat's line and these lines were measured. Intraclass Correlation Coefficient (ICC) was used to measure the strength of inter-and intra-rater agreement. RESULTS: The mean angle between the Blumensaat's line and the anatomical axis of the femur was 35.4 ± 3°. The mean angle between the Blumensaat's line and the line tangent to the anterior femoral cortex and the line tangent to the posterior femoral cortex were 34.5 ± 3° and 35.2 ± 3°, respectively. Excellent inter-and intra-rater reliabilities were observed between the measurements (ICC = 0.96 and ICC = 0.98, respectively). The angle between the Blumensaat's line and the line tangent to the posterior femoral cortex was significantly higher in participants aged < 38 years (p = 0.049). No other significant association was found between the angles and demographic characteristics of the patients. CONCLUSIONS: The expected mean angles between the Blumensaat's line and the distal femur were 34.3 to 35.4 degrees. This finding could be useful to determine the normal sagittal alignment of the distal femur. LEVEL OF EVIDENCE: II.

Evaluation of early complications, outcome, and mortality in Coronavirus Disease 2019 (COVID-19) infection in patients who underwent orthopedic surgery.

BACKGROUND: A higher mortality and morbidity rate has been reported in COVID-19 patients undergoing surgery. To reduce the morbidity and mortality rate in COVID-19 patients undergoing orthopedic procedures, we aimed to increase the threshold for surgical planning. METHODS: In a prospective cohort study, COVID-19 patients who underwent elective or emergent orthopedic surgery in three orthopedic surgery centers from February 2020 to September 2020 were included. In this period, 6751 patients were scheduled for orthopedic surgery. To increase surgical threshold planning, all patients with grade 5 of the American Society of Anesthesiologists (ASA) classification and patients with COVID-19 related moderate to severe pulmonary involvement were identified as high-risk patients and were excluded. RESULTS: 35 deaths occurred during the study. The frequency of deaths was significantly higher in patients with COVID-19, 6 (9.4%) than patients without COVID-19, 29 (0. 43%). The average hospitalization stay was 12.8 ± 12.1 days. The odds ratio (OR) for death was significantly higher in patients with COVID-19 than patients without COVID-19. [OR: 8.13, Confidence interval 95% (CI95%) (5.02-11.25), P: 0.001]. Four (6.3%) COVID-19-associated complications were recorded in this series that all were respiratory failure requiring unexpected postoperative ventilation. Twenty surgical complications (31.3%) were recorded. The odds ratio for ICU admission was significantly higher in patients with COVID-19 than patients without COVID-19. [OR: 5.46, CI 95% (2.68-8.68), P: 0.001]. CONCLUSIONS: An increased threshold for orthopedic surgery is suggested for COVID-19 patients with a mortality rate of 9.3%, which is less than the mortality rate in other studies. Level of evidence III.

Anatomic reconstruction of the medial collateral ligament in multi-ligaments knee injury using achilles allograft : a modification of Marx's technique.

Medial Collateral Ligament (MCL) injury may require operative treatment. Marx et al. described the latest technique for reconstruction of MCL. While good results have been reported using the Marx technique, some issues have been observed. To address the mentioned issues, a modification to the Marx technique has been devised. Eleven patients were enrolled and their ligaments were repaired by the fixation of allograft on the proximal and distal attachment footprints of the superficial MCL. For preventing loss of knee ROM, MCL and other ligaments were reconstructed in 2 separate stages. At the last follow up the ROM, knee ligament laxity and functional outcome scores, subjective (IKDC) and Lysholm score were evaluated and recorded. Knee motion was maintained in all cases. Two cases demonstrated 1+ valgus instability at 30 degrees of knee flexion. Both were treated for combined MCL and PCL tear, the rest were stable. The average IKDC-subjective score was 93 ± 4 and the average Lysholm score was 92 ± 3. All patients were satisfied and returned to their previous level of activity. In this technique, the superficial MCL was recon- structed closer to its anatomical construct. Patients didn't have any complaints of hardware under the skin and the need for a second surgery for hardware removal was avoided. Patients didn't have any complaints of hardware under the skin and the need for a second surgery for hardware removal was avoided. Also reconstructing the ligaments in 2 stages helped to preserve the knee motion. Level of Evidence : Level IV therapeutic.

The effect of local muscle vibration on clinical and biomechanical parameters in people with knee osteoarthritis: A systematic review.

Background: To identify and synthesize available published studies on the effect of local muscle vibration (LMV) on pain, stiffness, and function in individuals with knee OA. Methods: Five databases were searched to find relevant papers on April 29, 2020, including, PubMed, Scopus, EMBASE (Ovid), Science Citation Index, and COCHRANE Central Register for Controlled Trials (CENTRAL). Randomized controlled trials (RCTs) and nonrandomized-controlled-trials (non-RCTs), such as interrupted time series and prospective cohort studies were included. Two independent reviewers screened articles and assessed inclusion through predefined criteria. Participants' characteristics, study design, intervention characteristics, outcomes, and main results were collected independently by 2 reviewers. The risk of bias assessment of included studies was conducted using Cochrane risk of bias tools for RCTs and non-RCTs. Results: Six studies were included: 3 RCTs and 3 non-RCTs. The risk of bias in included studies was generally moderate to high. Improvement of pain, stiffness, and function following the application of LMV were reported in all studies. Conclusion: This review revealed the promising effect of LMV on pain, stiffness, function, and knee range of motion (ROM) improvements for individuals with knee Osteoarthritis (OA). However, further well-designed studies are required to have a convincing conclusion on the effect of LMV in individuals with knee OA.

The Efficacy of Intravenous Versus Topical Use of Tranexamic Acid in Reducing Blood Loss after Primary Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: Blood loss during and immediately after total knee arthroplasty (TKA) is among the most challenging concerns. It has been demonstrated that Tranexamic acid (TXA) can help to reduce perioperative blood loss. TXA can be used as an oral, topical or intravenous injection. Many studies evaluated the effectiveness of each route of administration but few works on a comparison between them. The current study aimed to compare the effectiveness of intravenous injection versus topical use of TXA in reducing perioperative blood loss after primary total knee arthroplasty. METHODS: Eighty-five patients who were a candidate for total knee arthroplasty were randomized into two groups: one group received Intravenous injection of 15 mg/kg TXA, 10 min before tourniquet inflation while the other group received 1 g diluted TXA during wound closure. The postoperative blood loss was estimated by measuring the whole drain output and also hemoglobin (HB) drops. Both groups compared based on the need for allogenic blood transfusion and also thromboembolic events. RESULTS: Patients who received topical TXA had a higher total drain output (p <0.0001) compared to intravenous injection. The hemoglobin drop also was more in the topical group although it was marginally significant (p =0.05). CONCLUSION: Intravenous injection of TXA is more effective in reducing postoperative blood loss after primary TKA compared to topical administration.

Short-term results of triathlon cementless versus cemented primary total knee arthroplasty.

BACKGROUND: Recent studies have demonstrated that aseptic loosening remains a leading cause of failure after total knee arthroplasty (TKA). Cementless fixation is a possible strategy for countering this problem. This study compared short-term survivorship and functional results of patients undergoing primary TKA with cementless versus cemented implants. METHODS: A multi-center database was utilized to identify 3849 patients undergoing primary TKA between 2012 and 2017 with a minimum two-year follow-up. Patients were divided into cementless (699), and cemented TKA (3150). The outcome of TKA including revision for aseptic or septic reasons, and other outcome variables were compared. Six hundred five patients from the cementless group (case) were matched with 605 patients from the cemented group (controls). Both groups were compared for outcomes and related variables. RESULTS: Both matched groups were similar in age, race, gender, height, weight, BMI, laterality, femoral component type, follow-up duration, preoperative and postoperative physical and mental health, and functional activities (all p-values>0.05). Although the cementless TKA group had more components in varus alignment (p = 0.015) and were taller (p < 0.001), the aseptic revision rate and time to failure were similar in both groups (p-values = 0.256 and 0.0890 respectively). The rate of revision for infection was also the same in both groups (p = 0.452). CONCLUSION: Cementless TKA demonstrated an equivalent rate of aseptic and septic failure when compared to cemented TKA in the short-term. Time to aseptic failure was also similar in both groups.

Symptomatic Benign Prostatic Hyperplasia: A Risk Factor for Periprosthetic Joint Infection in Male Patients.

BACKGROUND: Male patients undergoing total joint arthroplasty have a higher risk of periprosthetic joint infection (PJI) compared with female patients. The exact reason for this finding is not well known. This study aimed to determine if patients with symptomatic benign prostatic hyperplasia (BPH) are at increased risk of PJI. METHODS: A total of 12,902 male patients who underwent primary or revision total joint arthroplasty from January 2006 to April 2017 were retrospectively identified. The mean patient age was 62.47 years and the mean patient body mass index was 30.1 kg/m. The majority of patients were Caucasian or African American. Most surgical procedures involved the hip joints (57.8%) and were primary arthroplasties (86%). Of these patients, 386 (3%) had symptomatic BPH. Among this group, 250 patients with symptomatic BPH were identified and were matched in an approximate 1:3 ratio with 708 control patients. Using the International Consensus Meeting criteria, patients who developed PJI were identified. RESULTS: The PJI rate was 7.9% in the symptomatic BPH group and 2.8% in the control group. Multivariate regression analysis in unmatched groups showed that symptomatic BPH was a strong independent risk factor for PJI. After matching for variables related to outcomes, symptomatic BPH remained a significant risk factor for PJI (p = 0.01). CONCLUSIONS: Patients with symptomatic BPH had a higher risk of PJI compared with the control patients. This may partly explain the higher rate of PJI that is seen in male patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Relationship between electromyographic activity of knee joint muscles with vertical and posterior ground reaction forces in anterior cruciate ligament reconstructed patients during a single leg vertical drop landing task.

The objective of the present study is to examine the relation between activity patterns of knee joint muscles with vertical and posterior ground reaction forces (VGRF and PGRF, respectively) in patients after anterior cruciate ligament reconstruction (ACLR). Twenty males post-ACLR participated in this cross-sectional study. The association between muscle activity with VGRF and PGRF was assessed during a single leg vertical drop-landing task. There were strong negative associations between preparatory VL, VM and MG activity and PGRF (P< 0.05). Strong positive associations were found between reactive VM and LH activity with PGRF (P< 0.05). Preparatory co-activation of VM: MH had significant negative associations with VGRF (P< 0.05) and reactive co-activation of VL:LH had a significant positive relation with PGRF(P< 0.05). Greater preparatory activity and co-activation of knee muscles were associated with lower peak PGRF and VGRF, whereas greater reactive activity and co-activation of knee muscles was associated with greater peak PGRF and VGRF. According to our findings, both activity and co-activation of knee muscles during the preparatory phase were associated with reduced PGRF and VGRF, respectively in ACLR patients; thus, incorporating exercises in order to increase preparatory activity and co-activation of knee joint muscles into rehabilitation programs in ACLR patients seems necessary.

Tranexamic Acid Is Associated With Reduced Periprosthetic Joint Infection After Primary Total Joint Arthroplasty.

BACKGROUND: Previous studies have demonstrated preoperative anemia to be a strong risk factor for periprosthetic joint infection (PJI) in total joint arthroplasty (TJA). Allogeneic blood transfusion can be associated with increased risk of PJI after primary and revision TJA. Tranexamic acid (TXA) is known to reduce blood loss and the need for allogeneic blood transfusion after TJA. The hypothesis of this study is that administration of intravenous TXA would result in a reduction in PJI after TJA. METHODS: An institutional database was utilized to identify 6340 patients undergoing primary TJA between January 1, 2013 and June 31, 2017 with a minimum of 1-year follow-up. Patients were divided into 2 groups based on whether they received intravenous TXA prior to TJA or not. Patients who developed PJI were identified. All PJI patients met the 2018 International Consensus Meeting definition for PJI. A multivariate regression analysis was performed to identify variables independently associated with PJI. RESULTS: Of the patients included, 3683 (58.1%) received TXA and 2657 (41.9%) did not. The overall incidence of preoperative anemia was 16%, postoperative blood transfusion 1.8%, and PJI 2.4%. Bivariate analysis showed that patients who received TXA were significantly at lower odds of infection. After adjusting for all confounding variables, multivariate regression analysis showed that TXA is associated with reduced PJI after primary TJA. CONCLUSION: TXA can help reduce the rate of PJI after primary TJA. This protective effect is likely interlinked to reduction in blood loss, lower need for allogeneic blood transfusion, and issues related to immunomodulation associated with blood transfusion.

Comparison of Postoperative Complications and Survivorship of Total Hip and Knee Arthroplasty in Dialysis and Renal Transplantation Patients.

BACKGROUND: Chronic renal failure (CRF) is an established risk factor for surgical site infection (SSI) and periprosthetic joint infection (PJI) after primary total joint arthroplasty. However, there is limited literature comparing outcomes between patients who receive dialysis vs renal transplantation. We examined and compared clinical outcomes of patients receiving dialysis vs those who had a prior renal transplantation. METHODS: We retrospectively identified 107 patients undergoing primary total joint arthroplasty between 2000 and 2017, who were receiving dialysis (n = 50), or had a prior renal transplantation (n = 57). The cohorts were compared with respect to postoperative complications, including 90-day SSI, PJI, and failure resulting in revision procedure. Multivariate analysis was performed to determine independent risk factors for complications and revision. RESULTS: A significantly higher rate of postoperative complications was seen in dialysis patients (28.0%) compared with renal transplant (7.1%). In particular, increased SSI and PJI rates were observed in dialysis group compared with the transplant cohort (18.0% vs 3.5%). In addition, increased revision rates (24.0% vs 3.5%) and decreased survivorship for the implant were observed in dialysis patients. Multivariate analysis revealed that patients with renal transplant were less likely to require revision arthroplasty and that total knee arthroplasty (vs total hip arthroplasty) was an independent risk factor for failure in dialysis patients. CONCLUSION: This study provides further evidence that patients on dialysis who are on transplant list should await arthroplasty until transplant has taken place. In dialysis patients who are not transplant candidates, extreme care should be exercised, and additional strategies used to minimize the high complication rate that may be encountered.

Highlighting the Roles of Anemia and Aspirin in Predicting Ninety-Day Readmission Following Aseptic Revision Total Joint Arthroplasty.

BACKGROUND: Revision total joint arthroplasties (TJAs) are associated with an increased rate of complications. To date, it is unclear what drives readmission after aseptic revision arthroplasty and what measures can be taken to possibly avoid them. The purpose of this study is to (1) determine the reasons for readmission after aseptic revision TJA and (2) identify patient-specific or postoperative risk factors through a multivariate analysis. METHODS: A retrospective study examined 1503 cases of aseptic revision TJA between 2009 and 2016 at an urban tertiary care hospital. Eighty-seven cases (5.8%) of readmission within 90 days of index surgery were identified. Bivariate and multivariate analyses were performed to assess independent risk factors for readmission. RESULTS: The reasons for readmission were infection (38%), wound complications (22%), and dislocation/instability of the prosthetic joint (13%). Only preoperative anemia was associated with an increased odds ratio (OR) of readmission (OR 1.82, 95% confidence interval [CI] 1.126-2.970, P = .015), whereas postoperative venous thromboembolism prophylaxis with aspirin (OR 0.58, 90% CI 0.340-0.974, P = .039) and discharge to an inpatient rehab facility (OR 0.22, 95% CI 0.051-0.950, P = .042) were associated with significantly lower odds of readmission. CONCLUSION: Based on this single institutional study, addressing preoperative anemia and considering the implementation of aspirin for venous thromboembolism prophylaxis may be 2 targets to potentially reduce readmission after aseptic revision TJA.

Reverse Segond Fracture without Posterior Cruciate Ligament Injury - A report of Two Cases and Review of the Literature.

INTRODUCTION: Reverse Segond fracture is a cortical avulsion fracture off the medial tibial plateau of the knee, associated with tears of the posterior cruciate ligament (PCL), medial collateral ligament (MCL), medial meniscus, and probably the anterior cruciate ligament (ACL). Unlike Segond fracture, it is a very rare injury of the knee. CASE REPORT: Case one is a 24-year-old male with left tibial plateau and reverse Segond fracture with an magnetic resonance imaging (MRI) showing MCL avulsion, medial meniscus entrapped in fracture site and ACL tear but intact PCL. The second case is a 56-year-old female showing reverse Segond and lateral tibial plateau fracture confirmed by X-ray and computed tomography scan. MRI revealed intact PCL, detached medial meniscus from peripheral capsule and ACL injury. CONCLUSION: Based on this study and previous rare reports, reverse Segond fracture may not be accompanied by PCL injuries in all cases.

The Effect of Gentamycin in the Irrigating Solution to Prevent Joint Infection after Anterior Cruciate Ligament (ACL) Reconstruction.

BACKGROUND: Arthroscopic reconstruction of ACL is an effective method to restore knee stability after ACL rupture. Postoperative septic arthritis (SA) is very uncommon while the incidence of serious complications range between 0.14% and 1.8%. Some of the devastating consequences of septic arthritis can encompass hyaline cartilage damage, arthrofibrosis, and in rare cases amputation. The purpose of this study was to evaluate the effect of gentamicin irrigation solutions as a process to restrain septic arthritis following arthroscopic ACL reconstruction. METHODS: In this retrospective cohort study, 1464 patients who underwent ACL reconstruction with hamstring tendon autograft in our institution over 7 years (February 2008 to January 2015) were included. The patients were divided into two groups based on the type of intra-articular irrigation solution used during the surgery. Patients in Group 1 (Saline) received intra-articular irrigation with normal saline (0.9 % sodium chloride) solution, while those in Group 2 (Gentamycin) received intra-articular irrigation with gentamicin (80 mg/L) added to the normal saline solution. Data about postoperative infection, its course, management, and outcome were obtained from patients' records. RESULTS: Seven patients developed SA, four of whom were from SALINE group (2.2%) and three from Gentamycin group (0.23%). The incidence rate of SA after arthroscopic ACL reconstruction was significantly lower (P <0.05) when irrigated with gentamicin solution than merely with saline solution. CONCLUSION: Gentamicin irrigation solution has a preservative and protective effect against SA development following arthroscopic ACL reconstruction. We recommend evaluating this technique as a way in order to depreciate the prevalence of SA after ACL reconstruction.

Different References for Valgus Cut Angle in Total Knee Arthroplasty.

BACKGROUND: The valgus cut angle (VCA) of the distal femur in Total Knee Arthroplasty (TKA) is measured preoperatively on three-joint alignment radiographs. The anatomical axis of the femur can be described as the anatomical axis of the full length of the femur or as the anatomical axis of the distal half of the femur, which may result in different angles in some cases. During TKA, the anatomical axis of the femur is determined by intramedullary femoral guides, which may follow the distal half or near full anatomical axis, based on the length of the femoral guide. The aim of this study was to compare using the anatomical axis of the full length of the femur versus the anatomical axis of the distal half of the femur for measuring VCA, in normal and varus aligned femurs. We hypothesized that the VCA would be different based upon these two definitions of the anatomical axis of the femur. METHODS: Full-length weight bearing radiographs were used to determine three-joint alignment in normal aligned (Lateral Distal Femoral Angle; LDFA = 87º ± 2º) and varus aligned (LDFA >89º) femurs. Full-length anatomical axis-mechanical axis angle (angle 1) and distal half anatomical axis-mechanical axis angle (angle 2) were measured in all subjects by two independent orthopedic surgeons using a DICOM viewer software (PACS). Angles 1 and 2 were compared in normal and varus aligned subjects to determine whether there was a significant difference. RESULTS: Ninety-seven consecutive subjects with normally aligned femurs and 97 consecutive subjects with varus aligned femurs were included in this study. In normally aligned femurs, the mean value of angle 1 was 5.05° ± 0.76° and for angle 2 was 3.62° ± 1.19°, which were statistically different (P= 0.0001). In varus aligned femurs, the mean value of angle 1 was 5.42° ± 0.85° and for angle 2 was 4.23° ± 1.27°, which were also statistically different (P= 0.0047). CONCLUSION: The two different methods of outlining the anatomical axis of the femur lead to different results in both normal and varus-aligned femurs. This should be considered in determination of the valgus cut angle on pre-operative radiographs and be adjusted according to the length of the intramedullary guide.