Comparing the Water-Tight Closure of Barbed and Conventional Suture Under Static and Dynamic Conditions in an Ex-Vivo Human Knee Arthrotomy Model.

Background: Barbed suture has become popular for closure of the arthrotomy and overlying tissues in total knee arthroplasty. STRATAFIX Symmetric PDS Knotless Tissue Control Device, a unique and novel barbed suture, with barbs formed integral to the suture core provides greater suture strength than the more common cut barbed suture designs. It is the only barbed suture commercially available with an indication in high tension areas, such as fascia. The purpose of this study was to evaluate the use of this novel barbed suture in the formation of a water-tight arthrotomy closure, using a continuous suture pattern, compared to conventional Coated VICRYL (polyglactin 910) Suture, using an interrupted suture pattern, in a cadaveric knee arthrotomy. Methods: Twenty fresh-frozen cadaver knees underwent randomization to provide donor-paired matching of the knee arthrotomy closures using barbed suture in a continuous pattern or conventional suture in an interrupted pattern. Each specimen underwent 5 phases of testing that included 1) predynamic static leak testing; 2) dynamic motion leak testing; 3) postdynamic static leak testing; 4) suture release static leak testing; and 5) postsuture release dynamic motion leak testing, to assess the fluid leak rate. Results: Under the initial static conditions, watertightness was similar for the 2 types of sutures. However, in all subsequent phases of testing, continuous barbed suture created a better watertight closure than interrupted conventional suture. Conclusions: In this study, it was observed that closure of a knee arthrotomy using the novel barbed suture provided improved watertightness compared to conventional interrupted closure under dynamic conditions and suture release

Meloxicam versus Celecoxib for Postoperative Analgesia after Total Knee Arthroplasty: Safety, Efficacy and Cost

INTRODUCTION: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as part of multimodal analgesia in total knee arthroplasty (TKA). Selective cyclooxygenase (COX)-2 inhibitors (e.g., celecoxib) are believed to have fewer gastrointestinal (GI) adverse effects than nonselective NSAIDS. Meloxicam is less selective for COX-2 than celecoxib is and partially inhibits COX-1 at higher doses. Nonetheless, some surgeons prefer using nonselective NSAIDs because of their lower expense. METHODS: Four thousand nine hundred ninety-four patients who underwent TKA between January 2015 and February 2020 and took either celecoxib (n = 3,174), meloxicam 15 mg/d (n = 1,819), or meloxicam 7.5 mg/d (n = 451) were studied. Mutlimodal postoperative analgesia protocols were otherwise similar. GI bleeding and wound complication incidence were determined, as well as average 30-day prescription costs. RESULTS: GI bleeding incidence was similar in the three cohorts (P = 0.4). The incidence of wound complications did not significantly differ between the groups: 0.06%, 0.07%, and 0.22% in the celecoxib, meloxicam 15 mg/d, and meloxicam 7.5 mg/d groups, respectively (P = 0.06). Subsituting meloxicam for celecoxib results in an average savings of $183 per prescription. DISCUSSION: Meloxicam used at higher doses (15 mg/d) does not markedly increase the risk of GI or wound complications associated with COX-1 inhibition and is less costly for multimodal analgesia after TKA

Routine Patellar Resurfacing During Total Knee Arthroplasty is not Cost-Effective in Patients without Patellar Arthritis

During total knee arthroplasty (TKA), whether or not one should routinely resurface the patella is controversial. Leaving an unresurfaced patella following index TKA may lead to anterior knee pain (AKP), patellofemoral crepitus, and future secondary resurfacing operations. However, routinely resurfacing the patella (PR) may lead to patellar fracture, aseptic loosening, patellar instability, avascular necrosis, and patellar clunk. The purpose of the present study is to utilize the existing level one evidence to assess the cost-utility of routine patella resurfacing during primary TKA. Hypothesis: Selective resurfacing of the patella is more cost effective than routine patellar resurfacing during primary TKA.https://jdc.jefferson.edu/orthoposters/1000/thumbnail.jp

The Efficacy and Safety of Gabapentinoids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

© 2020 Elsevier Inc. Background: Gabapentinoids are commonly used as an adjunct to traditional pain management strategies after total joint arthroplasty (TJA). The purpose of this study is to evaluate the efficacy and safety of gabapentinoids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. Methods: The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies published prior to November 2018 on gabapentinoids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of gabapentinoids. Results: In total, 384 publications were critically appraised to provide 13 high-quality studies regarded as the best available evidence for analysis. In the perioperative period prior to discharge, pregabalin reduces postoperative opioid consumption, but gabapentinoids do not reduce postoperative pain. After discharge, gabapentin does not reduce postoperative pain or opioid consumption, but pregabalin reduces both postoperative pain and opioid consumption. Conclusion: Moderate evidence supports the use of pregabalin in TJA to reduce postoperative pain and opioid consumption. Gabapentinoids should be used with caution, however, as they may lead to an increased risk of sedation and respiratory depression especially when combined with other central nervous system depressants such as opioids

Management of Osteochondral Lesions of the Talus Using Autologous Chondrocyte Implantation

Category: Arthroscopy Introduction/Purpose: Osteochondral lesions of the talus (OLT) are frequent occurrences when patients sustain both traumatic and atraumatic ankle injuries with a report rate of up to 70% OLT in patients who sustain an ankle sprain or fracture. Surgical treatment options for OLT is either reparative or replacement and are dictated by characteristics of the lesion, including size and presence or absence of cysts. Periosteal-autologous chondrocyte implantation (P-ACI) or MACI (matrix-induced autologous chondrocyte implantation) is useful for lesions with or without cysts under 2.5cm2. We hypothesize that MACI will have the lowest reoperation rate and highest patient satisfaction rate in treating OLT. Methods: A systematic review was registered with PROSPERO and performed with PRISMA guidelines using three publicly available free databases. Therapeutic clinical outcome investigations reporting OLT outcomes with levels of evidence I-IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and compared between continents and countries. Statistics were calculated using Student’s t-tests, one-way ANOVA, chi-squared, and two-proportion Z-tests. Results: Nineteen articles met our inclusion criteria, which resulted in a total of 343 patients. Six studies pertained to arthroscopic MACI, 8 to open MACI, and 5 studies to open PACI. All studies were Level IV evidence. Due to study quality, imprecise and sparse data, and potential for reporting bias, the quality of evidence is low. In comparison of open and arthroscopic MACI, we found both advantages favoring open MACI (AOFAS and MOCART score). However, open MACI had higher complication rates versus arthroscopic (18.18% vs 0.78%, p = 0.002). In addition, the rate of impingement was noted to be significantly higher for the open technique of MACI with a rate of 10.61% as opposed to 0.78% for the arthroscopic technique (p = 0.01). Conclusion: No procedure demonstrates superiority or inferiority between the combination of open or arthroscopic MACI and PACI in the management of OLT less than 2.5 cm2. Ultimately well-designed randomized trials are needed to address the limitation of the available literature and further our understanding of the optimal treatment options

The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis

© 2018 Elsevier Inc. Background: A growing body of published research on tranexamic acid (TXA) suggests that it is effective in reducing blood loss and the risk for transfusion in total knee arthroplasty (TKA). The purpose of this network meta-analysis was to evaluate TXA in primary TKA as the basis for the efficacy recommendations of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty. Methods: We searched Ovid MEDLINE, Embase, Cochrane Reviews, Scopus, and Web of Science databases for publications before July 2017 on TXA in primary total joint arthroplasty. All included studies underwent qualitative and quantitative homogeneity testing. Direct and indirect comparisons were performed as a network meta-analysis, and results were tested for consistency. Results: After critical appraisal of the available 2113 publications, 67 articles were identified as representing the best available evidence. Topical, intravenous (IV), and oral TXA formulations were all superior to placebo in terms of decreasing blood loss and risk of transfusion, while no formulation was clearly superior. Use of repeat IV and oral TXA dosing and higher doses of IV and topical TXA did not significantly reduce blood loss or risk of transfusion. Preincision administration of IV TXA had inconsistent findings with a reduced risk of transfusion but no effect on volume of blood loss. Conclusions: Strong evidence supports the efficacy of TXA to decrease blood loss and the risk of transfusion after primary TKA. No TXA formulation, dosage, or number of doses provided clearly improved blood-sparing properties for TKA. Moderate evidence supports preincision administration of IV TXA to improve efficacy