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Taking aspirin after a joint replacement surgery could increase the risk of blood clots, according to a study published Aug. 23 in the Journal of the American Medical Association.

In the study, 9,711 patients who underwent hip and knee replacements were split into two groups. One group was treated strictly with aspirin after the surgery, while the other was only given the anticoagulant enoxaparin.

After 90 days, researchers evaluated both groups and found that venous thromboembolism occurred in 256 patients. The group treated strictly with aspirin were nearly twice as likely to develop VTE, according to the study.

The aspirin group saw a 3.45 percent VTE rate, while only 1.82 percent of the enoxaparin group experienced VTE.

Over the past 5 years, there has been a lot of discussion about “outpatient joint replacement.”

With all the emphasis on value-based care, joint replacement has been targeted as an
opportunity to reduce cost by movement from inpatient to outpatient admissions, resulting in a
reduction in skilled nursing admissions and decreased home health utilization. The BPCI
program led the way and continues to be successful in some markets. Many research articles
have been published in peer-reviewed journals citing the cost savings and the improvement in
outcomes. However, there still seems to be some hesitancy for migration to the ambulatory
surgery center. In 2016, the SG2 forecast was for 32% of joint replacements to be done in the
ASC by 2022. We haven’t even hit half of that. Why?

REASON #1: Site of Serve Shift. It is one thing to do an “outpatient joint” in the inpatient
setting where it is coded as HOPD (hospital outpatient department). You still have the safety net
of the big hospital; you still have your same staff, same rooms and it is, in fact, cheaper with a
reduced facility fee/DRG payment. However, to move it to the most cost-effective venue of the
outpatient surgery center it requires an entirely new care paradigm, from pre-admission testing
to patient education, staffing, sterile processing, care management, etc. So, the site of service
shift is not easy and, therefore, slow to progress and hit the SG2 forecast.

REASON#2: Alignment. To shift the site of service to the ASC, there must be alignment with
the surgeon, the payer and the ASC. Since it is a heavy lift to create programs and protocols
around a purely outpatient joint without an inpatient backdrop, systems have struggled to
figure it out and shift the volume to the ASC in large numbers. It is simply easier to keep doing
things the way you always have unless there is some incentive to change. Commercial
bundles and increased facility fees in physician-owned ASCs have seen excellent success in
certain markets.

REASON #3: Risk Assessment. The pandemic certainly gave outpatient joints a push and
many surgeons were forced to ask a different question as their OR’s were closed. We used to
ask “Who can I do at the ASC?” However, now we ask “Who CAN’T we do at the ASC?” To
help answer this question, we developed an evidence-based risk assessment tool, which is
built into our software program called ValereCARE, that we put all of our patients through. They
are assessed as type 1(healthy and safe to be done in the ASC), type 2 (comorbid conditions
needing clearances but can be done in the ASC if cleared) and type 3 (too many co-morbid
conditions and should be done in the hospital setting). We are embarking on a research study to
validate this tool and hope for others to be able to utilize it in their ASC’s.

We hope the industry progresses more and more towards ambulatory joint replacement as
surgeons and their staff get comfortable with this new value-based paradigm of care. It
requires alignment of payers, ASC executives and other industry leaders such as implant
companies. We will be gathering these various groups for the third time at our Valere Summit
on Ambulatory Joint Replacement on September 22-23 and all are welcome to come and take
part in this interactive value-based discussion. Registration and an agenda can be found at
www.valerebundledsolutions.com/summit.

 

The most prevalent ailment in adults is hip fracture, and arthroplasty is a technique in which the hip joint is replaced to restore proper joint function and treat pathological conditions. This technique has helped a lot of people who had significant hip injuries. Another treatment in hip arthroplasty is called hemiarthroplasty (HA). Studies have demonstrated that total hip arthroplasty (THA) produces superior outcomes than HA [1]. The anterior, lateral anterolateral, and posterior approaches are the most common arthroplasty procedures. One surgical training that includes the surgical technique for hip replacement is THA. THA is the finest surgical treatment for those with advanced hip osteoarthritis THA. The academic and technical abilities necessary for THA are taught to young orthopedic trainees in hospitals and surgical specialty facilities. Due to their lack of surgical expertise, trainees should be overseen by more seasoned and knowledgeable surgeons. Globally, over a million primary THA surgeries are performed each year. However, for adolescent, active patients, THA lifespan is a serious problem. THA has excellent long-term results, according to published literature [2]. Surgical skills are essential in the procedure of hip arthroplasty. THA is a helpful surgical procedure for individuals with advanced hip osteoarthritis. Many authors claimed that THA produced fantastic long-term results [2]. Several governmental efforts are also aimed at enhancing quality by providing incentives for surgeons to follow evidence-based treatment methods. This practice sought to estimate the individual effects of a surgeon, facility, standard of care procedure volume, and resource use in lower extremity THA [3].

In hip arthroplasty, modern surgical training has been developed, which will be helpful for the progression of the procedure. Patients whose hip joint has been degenerated by traumatic condition or disease may be able to experience pain relief and be back to regular work following a total hip replacement. In this kind of surgery, artificial implants are used to replace the femur ball and the hip socket that is damaged. Recently, surgical methods for hip replacement, particularly anterior (through the front of the hip) versus posterior (through the rear of the hip) treatments, have attracted new interest in the press and the medical community. The three primary forms of hip replacement are partial hip replacement, hip remerges, and THA. An operation known as arthroplasty can be performed to restore function to a joint. A joint may be rehabilitated by resurfacing the bones.

Surgical training

The surgical procedure involving implanting a complete hip prosthesis is a THA. It is performed in joint destruction due to degeneration or trauma. In our study, all patients served as control groups and we collected only the standard preliminary data or none at all regarding patients going about their everyday lives as usual. Physical function, the need quality of life, discomfort, mental health, hospital stay length, and post-surgical status issues were taken into consideration as criteria for postoperative care [4]. One of the most common orthopedic treatments is THA. Future orthopedic surgeons must be trained in order to meet demand. Meanwhile, such training raises a number of challenging issues. There have been worries that procedures conducted by trainees may result in worse patient outcomes, a decline in efficiency, and an increase in medical delivery costs as a result [5].

Direct anterior THA

The direct anterior route to the hip for total arthroplasty has been said to have various advantages over other popular techniques (Table 1). Patients can adapt to the direct anterior approach (DAA) irrespective of body type and hip problems. It is understood that specific native hip and pelvic anatomical characteristics make a plain front process more challenging [6].

Acetabular fracture in THA

THA is a widely used treatment for developed hip arthritis after acetabular fractures. A conservatively managed or operated condition may later lead to secondary arthritis necessitating a THA. Young individuals experience more acetabular fractures than their elderly counterparts. THA is acute or chronic in young or old patients with acetabular fractures. The surgeon must overcome some hurdles while performing a complete hip arthroplasty in an acetabular fracture, whether it is acute or delayed. The complications include fragments that prevent primary stability, amorphous anatomy, fibrosis and scar tissue between the pieces of bone, and potential bone fragment necrosis [7].

THA in femoral neck cracking

The ideal course of action for recent femoral neck fractures is still up for debate. The potential solutions include internal stabilization, HA, and total hip replacement (THA). THA is associated with better functional outcomes in independent, fit, and active patients, and a reduced chance of surgical repair. To prevent instability, a dual-mobility implant may be required [8]. Although there is a significant risk of instability following hip arthroplasty, whether complete (THA) or intermediate (HA), it is the standard for elderly patients with displaced intracapsular femoral neck fractures. Three different arthroplasties can be suggested: HAs and complete prosthesis without a dual mobility cup (DM THA) to reduce dislocation risk [9].

Spine rigidity in ankylosing spondylitis with THA in combined hips

The spine and hip joints are affected by ankylosing spondylitis (AS), which is characterized by progressive stiffness and function loss. Functional impairment is severe, involves the hip and spine, and is more common in younger age groups. Before THA, the spine’s rigidity related to AS needs to be assessed. Hips with a THA fusion show flexion, abduction, or extension deformities. A flexion or extension deformity can be seen in the hip fused to the TTH. Because there is no typical pelvic movement pattern while moving from standing to sitting, people cannot sit properly. The lumbar spine, spinopelvic flexibility, and hip flexors are the three variables that influence how the spine moves from standing to sitting [10]. The prevalence and results of hip involvement in AS have been assessed in some sizable investigations. Hip involvement can be identified through clinical examination, radiographic analysis, MRI, or ultrasound [11].

Complications in THA

An ordinary total hip replacement problem is heterotopic ossification (HO). Not all patient groups experience the same level of prevalence. Hip ankylosis, male sex, and having experienced HO in the past are all considered risk factors at a considerable level. AP radiograph is used as the sole diagnostic tool. Male sex, fixed prostheses, double hip joint arthroplasty, ankylosing arthritis, and hip joint ankylosis are thought to enhance the incidence of non-articular ossification, according to a recent meta-analysis [12]. Nonsteroidal anti-inflammatory medications (NSAIDs) are frequently used for HO following THA prophylaxis. However, it is unclear if NSAIDs, especially selective NSAIDs as opposed to nonselective NSAIDs, are effective for treating HO. Many studies have shown the effectiveness of NSAIDs in preventing HO. NSAIDs are therefore frequently used for the prevention of HO. But surgeons have become concerned about the possibility of NSAIDs’ gastrointestinal adverse effects [13].

THA and COVID-19 pandemic

COVID-19 is a highly contagious new coronavirus causing a worldwide epidemic. When COVID-19 symptoms manifest, patients frequently have lower respiratory symptoms such as fever, dry cough, weariness, muscle discomfort, and dyspnea. In addition to fractures, there are other possibly urgent surgical causes for THA that may call for early corrective surgery to reduce disability or the unnecessary harm that would be done to the patient if the operation was delayed [14]. Although the cancellation of elective surgery was necessary to conserve healthcare resources during the peak of the novel COVID-19 pandemic, recent data have shown that patients who had THA procedures cancelled are now experiencing worsening pain, a decline in physical activity, and an increase in anxiety [15]. To prevent the healthcare system from collapsing due to COVID-19, elective total joint arthroplasty procedures have been delayed. The majority of elective courses carried out in medical facilities around the world are THA treatments [16].

THA in the past, present, and future

Over the past three decades, there have been constant improvements in graft designs, biomedical techniques, surgical approaches, and knowledge of the physiological reconstruction of the hip, even though early designs had concerns with performance and even failure. These developments have improved THA clinical outcomes and implant survival rate.

Past

The author began his medical practice in 1990 with hybrid THA14, a low-friction form of THA3 that uses bonded and lacks a stable connection between the femoral and acetabular components. In the beginning, first-generation implants predominated. Several criteria were used to select the implants. An examination of the author’s early series of 76 primary hybrid THAs with a mean take of 15.5 years found that there were 23 (30.3%) articular surface reoperations (separated acetabular liner transfer, 12 instances; cup revision, 11 cases) with an average lifetime to revision of 11.5 years (range: 14-19.5 years )[17]. In this inquiry, an inadequate cementing procedure mainly caused an early failure of the coated femoral stem. Good cement mantle achievement may increase the survival rates [18].

Present

Beginning in 2000, the author started using a second-generation acetabular cup to solve the difficulties brought up by the author in his prior experiences. Specifically, the second-generation acetabular cups have enhanced liner locking mechanisms and polished tapered femoral stems. In the author’s study, 95 leading hybrid THAs with an average follow-up of 10 years were used. The excellent outcome of good implant survival and advance in a patient-reported result at the author’s institute further show that THA is a workable substitute, especially for young individuals with symptomatic symptoms [17].

Future

Future THAs are anticipated to focus further on some areas. Current THAs have great mid- and long-term outcomes when bearings are made of alternative materials. Thus, we may now concentrate on functional result advancement after THAs, particularly in the people of Asia, a region where way of existence differs substantially from that of the western population [17].

Surgical challenges of THA in tubercular arthritis of the hip

Hip osteoarticular tuberculosis can be a crippling condition that leads to severe hip arthritis and extensive cartilage loss and destruction. THA is a potent cure option for individuals with severe post-tuberculous arthritis, but it has historically generated debate because of worries about the possibility of disease recurrence. THA offers pain alleviation as well as mobility and stability [19]. To cure coxotuberculosis, comparing the overall curative effects of total hip replacement and hip arthrodesis (HA) is essential. THA is a successful therapy for severe tuberculous arthritis. When treating coxotuberculosis, THA is superior to HA [20]. THA has a solid track record of efficacy as a therapy method for quiescent hip tuberculosis. THA is a safe treatment that offers clinical alleviation and functional outcomes in advanced active hip tuberculosis cases. Complete postoperative antituberculosis chemotherapy is the key to reducing the chance of tuberculosis recurrence [21].

Perioperative care in THA

Numerous heterogeneous research studies have addressed every aspect of total hip replacement surgery’s improved surgical treatment. THA has a comparatively low rate of complications [22]. In total hip replacement, antibiotic prophylaxis should be standard practice; however, the selection of antibiotics should be based on price and local access [23]. The incidence of postoperative urine retention (POUR) after lower joint arthroplasty ranges from 0% to 75%. This wide range reflects the variations in POUR diagnosis and treatment [24]. When a multimodal analgesic regimen was delivered perioperatively in THA studies with intermediate risk, no extra analgesic impact of LIA relative to placebo was identified [25].

HIV in THA

THA should not be arbitrarily denied to HIV-positive patients. To avoid avoidable surgical problems, it is essential to identify all patients who are HIV positive and start them on HAART (highly active antiretroviral therapy) [26]. Life expectancy has risen as HIV medicines have advanced. As this group experiences pathological changes brought by ageing and avascular necrosis (AVN), the need for joint replacement is anticipated to rise (AVN) [27].

Trochanteric osteotomy in THA

The trochanteric osteotomy (TSO) technique allows for increased visibility and entry to the acetabulum and femoral canal for a range of factors. For both septic and disinfect revision, transfemoral approach , extended femoral trochanter osteotomy, and trochanteric slide osteotomy have been performed [28]. In femoral revised arthroplasty, the orthopedist frequently must choose between executing an expanded TSO and risking surgical fracture by trying to eliminate the femoral stem without an osteotomy [29]. A TSO has historically been necessary for successful glue removal and element reinsertion during THA [30].

THA for posttraumatic conditions

A significant portion of subsequent hip osteoarthritis is caused by posttraumatic arthritis [31]. The short-term efficacy of THA in treating posttraumatic osteoarthritis brought by acetabular rupture is excellent [32]. Uncemented THA can achieve good short-term effectiveness following transplant and is superior to cemented THA; yet, more analysis is required to regulate the efficacy over the medium and long term [33]. Uncemented THAs had a lower follow-up duration [34]. A wildly varying percentage of people who have received a kidney transplant have been documented to have femoral head osteonecrosis. Autoimmune reactions and poor bone quality increase the risk of aseptic release and infection when these patients undergo THA [35]. The treatment for AVN of the femoral head that is most frequently employed is total hip replacement [36].

Have you ever thought twice about leaving the house because you don’t want to deal with pain in your knee or hip. It probably won’t surprise you that joint pain is a common reason for feeling that way. In fact, almost 25% of adults in the United States have arthritis, according to the Centers for Disease Control and Prevention.

Over half of people with arthritis are of working age, which means they may be limited in the type of work they do because it is too painful to walk from a parking lot to a building or climb the stairs to an office.

According to WebMD, even people in their 30s may begin to experience osteoarthritis, a type of arthritis associated with the natural wearing away of joint cartilage through daily use — so old age is not the only sign that aches and pains may be connected to arthritis.

“Potential signs could include chronic swelling or inflammation in the joint, among other symptoms,” said Joshua Johnston, an orthopedic surgery specialist with St. Clare Hospital in Lakewood. “The most important thing a patient can do is have a conversation with their doctor about joint health and the pain they may be experiencing.”

Advances in joint replacement

There are more than 1 million hip and knee replacement procedures performed every year in the U.S., with even higher numbers expected as Baby Boomers age, according to research in the Journal of Bone and Joint Surgery.

“We put a lot of wear and tear on our bodies, especially our joints and bones,” Johnston said. “Over the past few years, some individuals and their physicians may have delayed or deferred certain orthopedic procedures, such as knee and hip replacements. While understandable, these delays can have consequences, such as impaired mobility, persistent aches and pains, and increased use of medications.”

While joint replacements have been happening for over 100 years, the procedure is continually being improved upon by doctors and researchers. For example, the Mako SmartRobotics treatment from medical technology company Stryker has made joint replacements safer and more effective.

It uses three-dimensional CT scans to help a doctor see anatomy clearly and make a personalized surgery plan. It also uses a technology called AccuStop, which helps a surgeon cut precisely without unnecessary cuts to healthy bone.

“Mako has been associated with less pain, less need for opiate analgesics, less need for inpatient physical therapy, and a reduced length of hospital stay when compared to manual techniques,” Johnston said.

The procedure is highly effective, with 96% of Mako partial knee replacement patients reporting that they were satisfied or very satisfied in a three-year follow-up survey.

The data insights provided by Mako SmartRobotics also shows surgeons a comprehensive view of their performance over time and teaches ways to improve patient satisfaction. This information helps surgeons stay focused on patients and invested in their recovery.

Tacoma Rainiers fans can earn free tickets

Tacoma Rainiers fans — including Silver Sluggers members and anyone else who is interested — can learn more about how advanced technology like the Mako SmartRobotics treatment can keep people with joint pain active.

Johnston will teach a free seminar at Cheney Stadium on Sept. 15 from 6 p.m. to 7:30 p.m. Dinner will be provided, and everyone attending will receive an undated ticket voucher to be used for a future game during the 2022 Minor League Baseball regular season.

Seating is limited for the event, so learn more and register at stryker.link/tacoma to save a spot.

By

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June 25, 2022

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Scientists from ExplantLab have identified a genotype that is associated with joint replacement failure in some patients. Based on these findings, the scientists developed a machine-learning algorithm called Orthotype, which uses a patient’s genotype and other factors to accurately predict the outcome of joint replacement surgery.

More than five million joint replacements are performed globally each year. Although most patients are satisfied with the results of their surgery, a significant number of joint replacements fail early, following adverse immune responses.

One of the most popular implant materials used in joint replacements is cobalt chrome (CoCr). When small particles from CoCr joints are released into the blood, it can lead to an immune response that results in pain and joint failure in some patients.

“Essentially, the immune system attacks the implant in a process similar to how a patient rejects an organ transplant,” explained David Langton, PhD, director of ExplantLab. “How quickly this happens is variable and unpredictable, but it appears to be dependent on the type of material, the amount of wear debris released, and other patient-specific factors.”

One of those patient-specific factors is their genes. The HLA genes play a central role in immune function, and Langton and his colleagues determined that patients with certain HLA genotypes are likely to develop responses to CoCr-containing implants. Their results were published in Communications Medicine.

Taking the research one step further, ExplantLab, working with bioengineers, medical staff, and patients from collaborating institutions, developed a machine-learning algorithm called Orthotype, which uses a patient’s genotype to provide a risk profile of that patient developing hypersensitivity to CoCr. Orthotype was developed and validated from the results from 606 patients implanted with metal hip replacements and resurfacings, each of whom had been followed for a mean duration of ten years.

This could herald a new era where it will become routine for patients to undergo genetic testing prior to receiving medical implants. Orthotype will identify patients more likely to have a reaction to a joint replacement made of CoCr components, helping surgeons select an implant based on the manufactured material most suited to the individual patient.

“This represents a significant advance in orthopedic care for patients,” said Langton, “with potentially significant financial repercussions for global healthcare systems, through the avoidance of repeat surgery.”

As populations around the world grow older and heavier, joint replacements are more common than ever. The number of joint replacement surgeries carried out globally is forecast to double over the next two decades.

The primary disadvantage of the total joint replacement (TJR) treatment is the critical loss of skeletal muscle attached to metal joint prostheses, resulting in the formation of fibrous scar tissue, ultimately leading to motor dysfunction. Consequently, tissue engineering technology may come to the rescue in addressing this issue.

Study: Improved Muscle Regeneration into a Joint Prosthesis with Mechano-Growth Factor Loaded within Mesoporous Silica Combined with Carbon Nanotubes on a Porous Titanium Alloy. Image Credit: gowithstock/Shutterstock.com

An article published in the journal ACS Nano demonstrated the fabrication of a two-layered mechano-growth factor (MGF) carrier, an alternative isoform of insulin-like growth factor-1 (IGF-1) expressed in response to mechanical stimulation.

The two-layered MGF carrier was made of a porous titanium alloy scaffold coated with mesoporous silica nanoparticles (MSNs) and carbon nanotubes (CNTs) via electrophoretic deposition (EPD). The two-layered coating exhibited a nanostructured topology with excellent MGF loading and extended-release performance via covalent bonding. 

In vivo studies on the fabricated scaffolds revealed that they preferentially promoted muscle growth than fibrotic tissue into titanium alloy structure and improved the muscle-derived mechanical properties, immunomodulation, and migration of satellite cells.

Thus, the fabricated MGF-loaded MSN and CNT-coated titanium alloy scaffolds were presented as a robust platform to restore the motor function of implanted joints like the natural joint by periprosthetic muscle regeneration.

Disadvantages of TJR Treatment and Titanium alloy in Prostheses

TJR treatment is popularly applied to replace natural joints with prostheses through arthroplasty surgery by orthopedic surgeons. However, in vivo degradation results in a shorter lifetime for these artificial joints compared to natural synovial joints. This occurs primarily because of the higher wear rates associated with artificial implant materials and the consequent adverse biological effect of the generated wear debris on bone mass/density and implant fixation.

Further, when compared to the initial TJR surgery, revision surgery of an implant is challenging, has a lower success rate, may induce additional damage to the surrounding tissues, and increases health care costs by one-third. Thus, a paradigm shift to periprosthetic muscle regeneration can increase the lifetime of prostheses. 

Motor dysfunction due to the connection loss between prostheses and muscle tissue is a common complaint of patients after TJR. Thus, the periprosthetic muscle regeneration into prostheses can help to regain normal joint motor function.

Titanium alloy is considered the best solution to address the above concerns and can match both the aesthetic and the functional requirements guaranteed by the implant. Titanium alloy exhibits low values of Young’s modulus and offers a wide span of properties.

Improved Periprosthetic Muscle Regeneration

MSNs have adjustable pore diameter, high surface area, large pore volume, and excellent biocompatibility and hence stand as promising candidates to deliver therapeutic agents. However, a few studies based on MSN-coated porous titanium alloy scaffolds mentioned the brittleness of MSNs. On the other hand, CNTs have high strength and elastic modulus compared to other reinforcement fibers. 

In the present work, CNTs were incorporated into MSNs as reinforcement fibers to relieve the strain between titanium alloy and MSNs. Integrating CNTs and MSNs into titanium alloy improved biomechanical behavior and imparted a sufficient biomolecule-loading capacity.

In the present work, a three-dimensionally (3D) printed porous titanium alloy was coated with a CNT-MSN layer via the EPD method, followed by loading of MGF into MSNs via covalent bonding with the help of 1-ethyl-3-(3- dimethylaminopropyl) carbodiimide hydrochloride (EDC) and N-hydroxysuccinimide (NHS). This helped achieve a long-term, slow release in prepared scaffolds.

Furthermore, the periprosthetic muscle regeneration into the prepared [email protected] coated titanium alloy scaffold was evaluated by conducting in vivo and in vitro studies. The results revealed an increased expression of myogenic genes and proteins, enhancing myoblast differentiation without biotoxicity, leading to the formation of myotubes and skeletal muscle fibers, indicating the potential of a prepared scaffold for periprosthetic muscle regeneration.

Additionally, the [email protected] coated titanium alloy scaffold activated the biological mechanism that induced the myoblast differentiation through the Akt/mTOR signaling pathway, indicated by the expression of Akt/mTOR signal-related proteins. Thus, proving the potential of MGF in serving as a local cell growth factor.

Conclusion

In summary, the two-layered MGF carrier that maintained a long-term release was composed of an inner CNT buffer layer and an outer [email protected] functional layer in the porous titanium alloy scaffold and was deposited using the EPD method.

The designed [email protected] porous titanium alloy scaffold enhanced the myoblast differentiation compared to the traditional prosthesis, without cytotoxicity, by increasing the expression of myogenic proteins and genes, forming myotubes and skeletal muscle fibers in vivo and in vitro.

The periprosthetic muscle regeneration into prostheses is needed to regain normal joint motor function. The scaffold fabricated in the present work was presented as a promising nanomaterial-based platform for periprosthetic muscle tissue regeneration into prostheses during recovery to regain normal joint motor function. 

Examining the biomechanism of myogenesis gave insights into the ability of titanium alloy based on the [email protected] scaffold in activating the Akt/mTOR signaling pathway, promoting myoblast differentiation.

Reference

Wei, X et al. (2022). Improved Muscle Regeneration into a Joint Prosthesis with Mechano-Growth Factor Loaded within Mesoporous Silica Combined with Carbon Nanotubes on a Porous Titanium Alloy. ACS Nano. https://pubs.acs.org/doi/10.1021/acsnano.2c04591

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Becker’s has reported on four studies since Aug. 23 that spine and orthopedic surgeons should know.

1. Taking aspirin after a joint replacement surgery could increase the risk of blood clots, according to a study published Aug. 23 in the Journal of the American Medical Association.

2. A study published in The Spine Journal concluded that patient improvement in neck pain was greater than improvement in arm pain following cervical disc replacements.

3. A study published in the July 2022 edition of Operative Neurosurgery supports the long-term use of Premia Spine’s Tops spinal joint replacement system.

4. Pacira BioSciences’ Exparel drug was found to be effective in treating pain after total knee replacements, according to a study. 

Conventional disease-modifying antirheumatic drugs (DMARDs) may usually be continued in patients with inflammatory arthritis or systemic lupus erythematosus (SLE) undergoing total knee or hip replacement, but the same is not necessarily true for more targeted agents, according to an updated guideline from two medical societies.

Biologic drugs and so-called JAK inhibitors should generally be stopped before arthritis patients have such procedures, and so should biologics such as belimumab (Benlysta) and immunosuppressants in patients with non-severe SLE, according to the guidance from the American College of Rheumatology and the American Association of Hip and Knee Surgeons, with Susan M. Goodman, MD, of the Hospital for Special Surgery in New York City, as lead author.

With severe lupus, however, it’s generally better to keep patients on their regular immunosuppressant regimen as well as belimumab. But for patients with severe SLE taking rituximab (Rituxan), the societies recommend scheduling surgery for the final month of the drug’s dosing cycle when blood levels have bottomed out.

The new guideline replaces an earlier version published in 2017 and takes account of new agents introduced in that time and better understanding of how traditional agents affect patients in the postoperative period, particularly the risk of joint infection.

In explaining the rationale for these guidelines, Goodman and colleagues noted that rheumatic disease patients are at substantially higher risk of periprosthetic infection following joint replacement relative to people without such conditions — by 50% in the case of rheumatoid arthritis. The immunomodulatory drugs that most of these patients take surely contribute to this increased risk.

That creates a management challenge, for simply withholding all the patients’ regular medications raises the likelihood of disease exacerbation. Flares may be less problematic than a deep joint infection, but the latter is relatively rare while flares are common when antirheumatic drugs are withdrawn. Thus, it becomes a question of balancing low risks of a potentially devastating complication against high risks of a lesser but still significantly adverse outcome.

For the update, committees from the two societies reviewed papers published through August 2021 addressing medication use in patients with inflammatory arthritis — rheumatoid arthritis, psoriatic arthritis spondyloarthritis, and juvenile idiopathic arthritis — and SLE undergoing hip and knee replacement.

The major recommendations — all rated as conditional — can be summarized as follows:

• Inflammatory arthritis and SLE patients may continue usual dosing with conventional DMARDs such as methotrexate, leflunomide, and hydroxychloroquine, as well as apremilast (Otezla) in the case of psoriatic arthritis.
• Arthritis patients taking biologic drugs including rituximab should stop them prior to surgery, and procedures should be scheduled for around the time the next doses would be due, to obtain some degree of washout.
• In non-severe lupus, patients should have drugs such as mycophenolate mofetil, azathioprine, cyclosporine, and tacrolimus stopped 1 week before surgery, and usual doses of belimumab and rituximab should be delayed.
• In severe lupus, conventional DMARDs as well as anifrolumab (Saphnelo) and voclosporin (Lupkynis) — both first approved in 2021 — should be continued at usual doses. Belimumab and rituximab can also be continued, but as mentioned above, surgery should be scheduled for late in the latter’s dosing cycle.
• No changes in corticosteroid medications are generally needed.
• In all cases where regular medications were stopped, they may be restarted when surgical wounds have started to heal and no signs of infection or other complications are evident.

As with any guideline, Goodman and colleagues emphasized that these are not intended as hard-and-fast rules and clinicians should engage in shared decision-making with patients to take account of their particular preferences and circumstances. “One patient representative on the current Voting Panel noted the anxiety that patients experience around changes to their medication regimens and urged clinicians to be cognizant of this important issue,” the authors wrote.

Goodman and colleagues also acknowledged significant gaps in the available evidence and called for new research, including prospective randomized trials, to “provide clearer answers” to questions about use of conventional DMARDs, for which such evidence is often lacking. “Perioperative management of biologics also needs more definitive study,” they added.

Notably, the guideline update did not address other issues related to joint replacement, such as risk of venous thromboembolism and other cardiovascular events.