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Stavros Tsotsolis, Eustathios Kenanidis, Vasileios F Pegios, Michael Potoupnis, and Eleftherios Tsiridis


  • This comprehensive systematic review aims to assess the literature regarding the risk of postoperative complications in patients undergoing total joint arthroplasty (TJA) with concomitant thyroid dysfunction.


  • Studies were identified by searching PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, and (end of search: May 2022).

Inclusion criteria

  • Randomized control and case-control studies, cohort and observational clinical studies were included, which focused on postoperative complications and outcomes of patients undergoing TJA operations of major joints (knee, hip, ankle, elbow). All studies were assessed according to their level of evidence, the number and age of patients, and treatment complications.


  • Nine studies were included in this review that demonstrated a higher risk of postoperative anemia, perioperative blood loss, hemoglobin decrease, and transfusion rates in hypothyroid patients after TJA.


  • Hypothyroidism has been identified as a potential but modifiable risk factor for increased rates of deep venous thrombosis, acute kidney injury, pneumonia, and non-specified cardiac complications among hypothyroid patients who underwent TJA as well as increased rates of periprosthetic joint infection. No significant differences in the prosthesis-related mechanical complication rates have been calculated when comparing hypothyroid and euthyroid patients.

Richard N de Steiger, Brian R Hallstrom, Anne Lübbeke, Elizabeth W Paxton, Liza N van Steenbergen, and Mark Wilkinson

  • Recent concerns surrounding joint replacements that have a higher than expected rate of revision have led to stricter controls by regulatory authorities with regards to the introduction of new devices into the marketplace.

  • Implant post-market surveillance remains important, and joint replacement registries are ideally placed to perform this role. This review examined if and how joint replacement registries identified outlier prostheses, outlined problems and suggested solutions to improve post-market surveillance.

  • A search was performed of all joint replacement registries that had electronic or published reports detailing the outcomes of joint replacement. These reports were examined for registry identification of outlier prostheses. Five registries publicly identified outlier prostheses in their reports and the methods by which this was performed, and three others had internal reports.

  • Identification of outlier prostheses is one area that may improve overall joint replacement outcomes; however, further research is needed to determine the optimum methods for identification, including the threshold, the comparator and the numbers required for notification of devices.

  • Co-operation of registries at a global level may lead to earlier identification of devices and thereby further improve the results of joint replacement.

Xiang-Dong Wu, Yixin Zhou, Hongyi Shao, Dejin Yang, Sheng-Jie Guo, and Wei Huang


  • During the past decades, robotic-assisted technology has experienced an incredible advancement in the field of total joint arthroplasty (TJA), which demonstrated promise in improving the accuracy and precision of implantation and alignment in both primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, revision TJA remains a technically challenging procedure with issues of large-scale bone defects and damage to nearby anatomical structures. Thus, surgeons are trying to harness the abilities of robotic-assisted technology for revision TJA surgery.


  • PubMed, Embase, Cochrane Library, and Google Scholar were comprehensively searched to identify relevant publications that reported the application of robotic-assisted technology in revision TJA.


  • Overall, ten studies reported the use of the robotic system in revision TJA, including active (ROBODOC) and semi-active (MAKO and NAVIO) systems. One clinical case reported conversion from hip fusion to THA, and three studies reported revision from primary THA to revision THA. Moreover, four studies reported that robotic-assisted technology is helpful in revising unicompartmental knee arthroplasty (UKA) to TKA, and two case reports converted primary TKA to revision TKA. In this study, we present the latest evolvements, applications, and technical obstacles of robotic-assisted technology in the revision of TJA and the current state-of-the-art.


  • Current available evidence suggests that robotic-assisted technology may help surgeons to reproducibly perform preoperative plans and accurately achieve operative targets during revision TJA. However, concerns remain regarding preoperative metal artifacts, registration techniques, closed software platforms, further bone loss after implant removal, and whether robotic-assisted surgery will improve implant positioning and long-term survivorship.

Leonard Christianto Singjie, Reynaldo Halomoan, Ifran Saleh, Endrotomo Sumargono, and Erica Kholinne


  • Patients undergoing major orthopedic surgeries, such as total hip replacement (THR), total knee replacement (TKR), and trauma surgery, are at an elevated risk of venous thromboembolism (VTE), causing significant morbidity and mortality. Previous studies have investigated aspirin as a thromboprophylactic agent for arthroplasty, besides trauma surgery. Therefore, we sought to analyze the efficacy of aspirin compared to that of other anticoagulants for VTE prophylaxis in patients undergoing major orthopedic surgeries.


  • This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study protocol was registered with the PROSPERO register. Randomized controlled trials that investigated the use of aspirin for thromboprophylaxis in major orthopedic lower limb surgeries were included and analyzed. Quality analysis of the literature and level of evidence were assessed. The primary clinical outcome was VTE. Secondary clinical outcomes included mortality, bleeding events, and wound complications.


  • Eight high-quality studies with level 2 evidence (published within 2006–2021) were included, comprising 6220 patients. The incidence of VTE with aspirin was not found to be more significant than other anticoagulants (risk ratio (RR) = 1.18, 95% CI: 0.89–1.58, P = 0.25). Regarding secondary outcomes, there were no significant differences between aspirin and other anticoagulants (mortality (RR = 1.40, 95% CI: 0.27–7.23, P = 0.69), bleeding events (RR = 0.89, 95% CI: 0.57–1.39, P = 0.61), or wound complications (RR = 0.64, 95% CI: 0.30–1.35, P = 0.24)).


  • The current meta-analysis did not show any difference between aspirin and other anticoagulants as thromboprophylactic agents in preventing VTE in patients who underwent major orthopedic surgeries.

İlker Eren, Cemil Cihad Gedik, Uğur Kılıç, Berk Abay, Olgar Birsel, and Mehmet Demirhan

  • Facioscapulohumeral muscular dystrophy (FSHD) is a common hereditary disorder which typically results in scapular winging due to wasting of the periscapular muscles affected by this condition.

  • Scapulothoracic arthrodesis (STA) is the current surgical treatment for FSHD patients with severe winging and preserved deltoid muscle.

  • There are several different techniques in the literature such as multifilament cables alone and cable or cerclage wires combined with single or multiple plates. We prefer cables without plates as it provides independent strong fixation points and strongly recommend utilization of autograft.

  • The functional results of studies report that regardless of the technique used, shoulder elevation and thus quality of life is improved, as shown with outcome scores.

  • There are several complications associated with STA. Pulmonary complications are common and usually resolve spontaneously. Meticulous surgical technique and effective postoperative analgesia may reduce the incidence. Scapular complications which are associated with the fixation may be encountered in the early or late period, which are related to the learning curve of the surgeon.

  • In conclusion, STA is a reliable solution to a major problem in FSHD patients that helps them maintain their activities of daily living until a cure for the disease is found. A successful result is strongly dependent on patient selection, and a multidisciplinary team of neurologists, geneticists and orthopaedic surgeons is required to achieve good results.

A Frodl, N Geisteuer, A Fuchs, T Nymark, and H Schmal


  • Incisional negative pressure wound therapy (iNPWT) has shown effectiveness in the treatment of high-risk surgical wounds. Especially patients with diabetes-induced peripheral arterial disease undergoing major limb amputation have a high intrinsic risk for post-surgical wound infections. While normal gauze wound dressings do not cause stimulation of microvasculature, iNPWT might improve wound healing and reduce wound complications. The purpose of this study was to systematically review the literature for rates of wound complications and readmissions, as well as post-surgical 30-day mortality.


  • We conducted a systematic review searching the Cochrane, PubMed, and Ovid databases. Inclusion criteria were the modified Coleman methodology Score >60, non-traumatic major limb amputation, and adult patients. Traumatic amputations and animal studies were excluded. Relevant articles were reviewed independently by referring to the title and abstract. In a meta-analysis, we compared 3 studies and 457 patients.


  • A significantly overall lower rate of postoperative complications is associated with usage of iNPWT (odds ratio (OR) = 0.52; 95% CI: 0.30–0.89; P = 0.02). There was no significant improvement for 30-day mortality, when iNPWT was used (OR= 081; 95% CI: 0.46 – 1.45; P = 0.48). Nevertheless, we did not note a significant difference in the readmission rate or revision surgery between the two groups.


  • Overall, the usage of iNPWT may reduce the risk of postoperative wound complications in major lower limb amputations but does not improve 30-day mortality rates significantly. However, to anticipate surgical-site infection, iNPWT has shown effectiveness and thus should be used whenever applicable.

Di Zhao, Ling-feng Zeng, Gui-hong Liang, Jian-ke Pan, Ming-hui Luo, Yan-hong Han, Jun Liu, and Wei-yi Yang


  • Considering the adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids for treating osteoarthritis (OA), development of drugs that are more effective and better tolerated than existing treatments is urgently needed. This systematic review aimed to evaluate the efficacy and safety of anti-nerve growth factor (NGF) monoclonal antibodies vs active comparator therapy, such as NSAIDs and oxycodone, in treating hip or knee OA.


  • Databases were comprehensively searched for randomized controlled trials (RCTs) published before January 2022. Efficacy and safety outcomes were assessed.


  • Six RCTs that included 4325 patients were identified. Almost all the RCTs indicated that moderate doses of anti-NGF monoclonal antibody treatment significantly improved efficacy outcomes based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, the WOMAC physical function score and the Patient’s Global Assessment compared with those of the active comparator. At least half of the RCTs indicated that the incidence of severe adverse events, withdrawals due to adverse events (AEs) and total joint replacement were not significantly different between anti-NGF monoclonal antibody treatment and active comparator therapy, but the outcomes of some studies may have been limited by a short duration of follow-up. Most RCTs suggested that anti-NGF monoclonal antibody treatment had a lower incidence of gastrointestinal and cardiovascular AEs. However, the majority of RCTs reported a higher incidence of abnormal peripheral sensation with anti-NGF monoclonal antibody treatment. Furthermore, the higher incidence of rapidly progressive osteoarthritis (RPOA) with anti-NGF monoclonal antibody treatment should also not be overlooked, and the identification of patient characteristics that increase the risk of RPOA is critical in further studies.


  • Based on the current research evidence, anti-NGF monoclonal antibodies are not yet a replacement for analgesic drugs such as NSAIDs but might be a new treatment option for hip or knee OA patients who are intolerant or unresponsive to nonopioid or opioid treatment. Notably, however, considering the inconsistency and inconclusive evidence on the safety outcomes of recent studies, more research is needed, and long-term follow-up is required.

M M Morlock, E Gomez-Barrena, D C Wirtz, A Hart, and J P Kretzer

  • In the early days of total joint replacement, implant fracture, material problems and wear presented major problems for the long-term success of the operation.

  • Today, failures directly related to the implant comprise only 2–3% of the reasons for revision surgeries, which is a result of the material and design improvements in combination with the standardization of pre-clinical testing methods and the post-market surveillance required by the legal regulation.

  • Arthroplasty registers are very effective tools to document the long-term clinical performance of implants and implantation techniques such as fixation methods in combination with patient characteristics.

  • Revisions due to implant failure are initially not reflected by the registries due to their small number.

  • Explant analysis including patient, clinical and imaging documentation is crucial to identify failure mechanisms early enough to prevent massive failures detectable in the registries.

  • In the past, early reaction was not always successful, since explant analysis studies have either been performed late or the results did not trigger preventive measures until clinical failures affected a substantial number of patients.

  • The identification of implant-related problems is only possible if all failures are reported and related to the number of implantations.

  • A system that analyses all explants from revisions attributed to implant failure is mandatory to reduce failures, allowing improvement of risk assessment in the regulatory process.

Peter van Schie, Shaho Hasan, Leti van Bodegom-Vos, Jan W Schoones, Rob G H H Nelissen, and Perla J Marang-van de Mheen

  • In order to improve care for total hip and knee arthroplasties (THA/TKA), hospitals may want to compare their performance with hospitals in other countries. Pooling data across countries also enable early detection of infrequently occurring safety issues. We therefore aimed to assess the between-hospital variation and definitions used for revision, readmission, and complications across countries.

  • PubMed, Embase, Web of Science, Cochrane library, Emcare, and Academic Search Premier were searched from January 2009 to August 2020 for studies reporting on: (i) primary THA/TKA; (ii) revision, readmission, or complications; and (iii) between-hospital variation. Most recent registry reports of Network of Orthopedic Registries of Europe members were also reviewed. Two reviewers independently screened records, extracted data, and assessed the risk of bias using the Integrated quality Criteria for the Review Of Multiple Study designs tool for studies and relevant domains for registries. We assessed agreement for the following domains: (i) outcome definition; (ii) follow-up and starting point; (iii) case-mix adjustment; and (iv) type of patients and hospitals included.

  • Between-hospital variation was reported in 33 (1 high-quality, 13 moderate-quality, and 19 low-quality) studies and 8 registry reports. The range of variation for revision was 0–33% for THA and 0–27% for TKA varying between assessment within hospital admission until 10 years of follow-up; for readmission, 0–40% and 0–32% for THA and TKA, respectively; and for complications, 0–75% and 0–50% for THA and TKA, respectively. Indicator definitions and methodological variables varied considerably across domains.

  • The large heterogeneity in definitions and methods used likely explains the considerable variation in between-hospital variation reported for revision, readmission, and complications , making it impossible to benchmark hospitals across countries or pool data for earlier detection of safety issues. It is necessary to collaborate internationally and strive for more uniformity in indicator definitions and methods in order to achieve reliable international benchmarking in the future.

Hua Luo, Yu Ren, Yongwei Su, Feng Xue, and Zhenghua Hong

  • The purpose of the study was to evaluate the effect of local application of vancomycin powder (VP) to prevent surgical site infections (SSIs) after posterior spine surgery.

  • A comprehensive search of Web of Science, EMBASE, Pubmed, Ovid, and Cochrane Library databases for articles published was performed to collect comparative studies of intrawound vancomycin in posterior spine surgery before March 2021. Two reviewers independently screened eligible articles based on the inclusion and exclusion criteria, assessed the study quality, and extracted the data. Revman 5.4 software was used for data analysis.

  • A total of 22 articles encompassing 11 555 surgical patients were finally identified for meta-analysis. According to the information provided by the included literature, the combined odds ratio showed that topical use of VP was effective for reducing the incidence of SSIs (P< 0.00001) after posterior spine surgery without affecting its efficacy in the treatment of deep infections (P< 0.00001). However, there is no statistical significance in superficial infections. In a subgroup analysis, VP at a dose of 1, 2, and 0.5–2 g reduced the incidence of spinal SSIs. The result of another subgroup analysis suggested that local application of VP could significantly reduce the risk of SSIs, whether it was administered after posterior cervical surgery or thoracolumbar surgery. Moreover, the percentage of SSIs due to gram-positive germs (P< 0.00001) and MRSA (P< 0.0001) could reduce after intraoperative VP was used, but did not significantly reduce to gram-negative germs.

  • The local application of VP appears to protect against SSIs, gram-positive germs, and MRSA (methicillin-resistant Staphylococcus aureus) infections after the posterior spinal operation.