The role of fibrin sealants in orthopaedic surgery

Preparation and In Vitro Characterization of Lactococcus lactis-Loaded Alginate Particles as a Promising Delivery Tool for Periodontal Probiotic Therapy

Probiotic microorganisms are used in a variety of food supplements and medical formulations to promote human health. In periodontal therapy, probiotics are mainly used in the form of gels, tablets or rinses that often tend to leak from the periodontal pocket, resulting in a strongly reduced therapeutic effect. In this pilot in vitro study, we present biodegradable alginate-based particles as an alternative, highly efficient system for a periodontal delivery of probiotic bacteria to the inflammation site. For this purpose, Lactococcus (L.) lactis was encapsulated using a standardized pump-controlled extrusion-dripping method. Time-dependent bacterial release in artificial saliva was investigated over 9 days. The effect of freeze drying was explored to ensure long-term storage of L. lactis-loaded particles. Additionally, the particles were bound to dentin surface using approved bioadhesives and subjected to shear stress in a hydrodynamic flow chamber that mimics the oral cavity in vitro. Thus, round particles within the range of 0.80-1.75 mm in radius could be produced, whereby the diameter of the dripping tip had the most significant impact on the size. Although both small and large particles demonstrated a similar release trend of L. lactis, the release rate was significantly higher in the former. Following lyophilization, particles could restore their original shape within 4 h in artificial saliva; thereby, the bacterial viability was not affected. The attachment strength to dentin intensified by an adhesive could resist forces between 10 and 25 N/m2. Full degradation of the particles was observed after 20 days in artificial saliva. Therefore, alginate particles display a valuable probiotic carrier for periodontal applications that have several crucial advantages over existing preparations: a highly stable form, prolonged continuous release of therapeutic bacteria, precise manufacturing according to required dimensions at the application site, strong attachment to the tooth with low risk of dislocation, high biocompatibility and biodegradability.

Bone adhesive materials: From bench to bedside

Biodegradable bone adhesives represent a highly sought-after type of biomaterial which would enable replacement of traditional metallic devices for fixation of bone. However, these biomaterials should fulfil an extremely large number of requirements. As a consequence, bone-adhesive biomaterials which meet all of these requirements are not yet commercially available. Therefore, this comprehensive review provides an extensive overview of the development of bone adhesives from a translational perspective. First, the definition, classification, and chemistry of various types of bone adhesives are highlighted to provide a detailed overview of this emerging class of biomaterials. In this review we particularly focused studies which describe the use of materials that are capable of gluing two pieces of bone together within a time frame of minutes to days. Second, this review critically reflects on i) the experimental conditions of commonly employed adhesion tests to assess bone adhesion and ii) the current state-of-the-art regarding their preclinical and clinical applicability.

Augmentation of rotator cuff repair with gelatin-resorcin-formalin glue: a biomechanical study

INTRODUCTION

Rotator cuff tendons are typically reattached to the proximal humerus using transosseous sutures or suture anchors. Their primary mode of failure is at the tendon-bone interface.

METHODS

We investigated the addition of an adhesive, gelatin-resorcin-formalin (GRF) glue, to a single-row rotator cuff repair (RCR) on ex vivo sheep models. We hypothesised the addition of GRF glue would increase the repair construct strength. The study consisted of three groups of six sheep infraspinatus tendons with an inverted-mattress stitch, tension-band configuration. Group 1 was the control group where no glue was applied. Group 2 involved applying 2 × 2 cm of GRF glue to the infraspinatus footprint and a 2-min curing time. Group 3 allowed for a 15-min cure time.

RESULTS

Failure occurred at the tendon-bone-suture interface in 6/6 of the control group, and 4/6 from groups 2 and 3. Failure occurred via the suture pulling out of the anchor in 2/6 of groups 2 and 3. No significant differences were noted between all three groups in ultimate failure load, repair stiffness or total energy to failure (p > 0.05).

DISCUSSION

The addition of GRF glue to the tendon-bone-suture interface did not enhance RCR strength in an ovine model.

Efficacy and Safety of Bioabsorbable Bone Hemostatic Agent in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

Although a bioabsorbable bone hemostatic agent (BBHA) was developed approximately 20 years ago to overcome the shortcomings of conventional bone wax, its bleeding control capacity has not yet been studied. This study was aimed at investigating the efficacy and safety of BBHA in total knee arthroplasty (TKA). Sixty-two patients who underwent unilateral primary TKA for knee osteoarthritis were included and randomized to the control or BBHA group. Before releasing the tourniquet, BBHA was applied on the bone-cut surface that was not covered by implants. The primary variable was the drainage volume during the postoperative period. The secondary outcomes were total estimated blood loss (EBL), hemoglobin level, hematocrit level, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, range of motion (ROM), pain visual analog scale (VAS) score, and rate of complications. There were no significant differences in drainage volume or EBL between the 2 groups. Hemoglobin and hematocrit levels were higher in the BBHA group during the 4-week postoperative period; however, the intergroup differences were not significant. The ESR, CRP, ROM, and pain VAS scores in the BBHA group were not significantly different from the corresponding values in the control group. No specific complications were observed. Although BBHA was found to be safe without complications, it did not decrease bleeding after TKA in general cases. Further studies are necessary to evaluate the efficacy of BBHA in patients with coagulation problems.

Clinical and imaging effects of corticosteroids and platelet-rich plasma for the treatment of chronic plantar fasciitis: A comparative non randomized prospective study

The purpose is to compare the effectiveness and imaging changes (US and MRI) between PRP and corticoids injections for the treatment of chronic plantar fasciitis, using clinical results evaluated by the visual analogue scale (VAS), the AOFAS clinical rating system and the modified Roles and Maudsley score, and using imaging results (US and MRI). Our hypothesis is that PRP infiltrations are a more effective therapeutic method than infiltrations with corticosteroids. A single-centre, non randomized, prospective study of 40 consecutive patients (40 feet) with plantar fasciitis who had not responded to conservative treatment for at least 6 months was undertaken. The first 20 consecutive patients (group A) were treated with two local injections of 4ml of a PRP concentrate. The second group of 20 patients (group B) were injected with 4ml of 40mg methylprednisolone. Clinical results were evaluated using a visual analogue scale (VAS), the AOFAS clinical rating system and the modified Roles and Maudsley score, with a mean follow-up of 33 months. Imaging results were evaluated by plantar US after 3 and 6 months, and MRI after 6 months. There were no complications arising from the treatment. In group A (PRP), the VAS changed from 8.25 to 1.85 and the AOFAS from 47.05 to 92.10. In group B (methylprednisolone), the VAS changed from 7.7 to 5.30 points and from 50.85 to 49.75 on the AOFAS. In the imaging tests, the thickness of the fascia in group A changed from 7.90mm to 4.82mm over 3 months following the injection, maintaining this thickness in the biannual controls. In group B the change was from 8.05mm to 6.13mm over 3 months, increasing to 6.9mm after 6 months. The other inflammatory signs improved in all cases, especially in group A. The treatment of chronic plantar fasciitis by two injections of PRP is a safe, more efficient and long-lasting method than corticoid injections.

The effect of a fibrin sealant on knee function after total knee replacement surgery. Results from the FIRST trial. A multicenter randomized controlled trial

Background

Total knee replacement (TKR) is increasingly performed in short term hospital stay, making same day mobilization an important issue is after surgery. This implies little joint effusion by reducing intra-articular blood loss, which will enhance knee range of motion. The application of a topical fibrin sealant on the intraoperative bare bone and synovial tissue may contribute to better early full mobilization and thus improved functional outcomes. Since ambulation with a fully extended knee is less strenuous, we hypothesized that patients who received fibrin sealant would demonstrate improved early knee extension after six weeks compared to patients who received standard care.

Methods

A multicenter randomized controlled trial in a consecutive series of osteoarthritis patients scheduled for TKR surgery. Participants were randomized to receive fibrin sealant or not before closing the knee joint capsule. Primary outcome was change in knee extension angle(°) at short term (2 weeks) follow-up (cExt). Secondary outcomes were 6-week extension angle, knee flexion angle, hemoglobin loss, blood transfusion rates, complication rates, the Knee Society Score, and the KOOS and EQ5D questionnaires.

Results

When data on primary outcome became available from 250 patients, an interim analysis was performed by an independent Data Safety Monitoring Board for safety and effectivity assessment. This analysis showed that sufficient patients were included to detect a cExt of 10° between both groups. Inclusion was stopped however, all in the meantime included patients were treated according to their randomization. A total of 466 were available for analysis. Both groups were comparable in terms of baseline characteristics. The estimated mean cExt difference was 0.2° (95%CI -0.5 to 0.9). No differences in secondary outcomes were found.

Conclusions

No beneficial effects or side effects were found of a topically applied fibrin sealant during TKR surgery. These results discourage the clinical use of a fibrin sealant in TKR.

Trial registration

Dutch Trial Register, NTR2500.

Tisseel's impact on hemostasis for 2-3 and 4-6-level lumbar laminectomies

Background:

Tisseel (Baxter International Inc., Westlake Village, CA, USA), a fibrin sealant, was originally devised to strengthen repairs of spinal cerebrospinal fluid (CSF) fistulas. Here, we evaluated how Tisseel correlated with hemostasis (e.g., defined as reduced postoperative drainage, time to drain removal, length of stay (LOS), and postoperative transfusion requirements) in 58 patients undergoing 2–3 vs. 79 patients having 4–6 level lumbar laminectomies.

Methods:

We assessed how Tisseel correlated with hemostasis in 58 patients undergoing 2–3 level laminectomies/stenosis (with 48 herniated discs and 20 synovial cysts, 1 degenerative spondylolisthesis) vs. 79 having 4–6 level laminectomies/stenosis (with 39 lumbar discs, 45 synovial cysts, and 26 degenerative spondylolisthesis).

Results:

Following 2–3 level laminectomies, the average drainage on postoperative day 1 was 87.26 cc, and on day 2 was 59.62 cc; most drains were removed and the majority of patients were discharged on postoperative day 2, requiring no transfusions. After 4–6 level decompressions, greater postoperative drainage was observed on postoperative days 1 (e.g., 156.63 cc), and 2 (115.8 cc), and many were continued for 3 (85.7 cc; 44 patients), and 4 postoperative days (93.6: 6 patients) respectively. Drains were typically removed and patients were discharged on postoperative days 3 and 4, with just 6 requiring transfusions. Notably, there were four CSF fistulas for patients undergoing 4–6 level laminectomies; one had a large disc hernation in conjunction with postoperative scare, while three had massive calcified synovial cysts extending to/through the dura.

Conclusions:

Utilizing Tisseel as a hemostatic allowed us to quantitate hemostasis (the average postoperative drainage, time to drain removal, LOS, and postoperative transfusion requirements) for those undergoing 2–3 level laminectomies vs. 4–6 level procedures with large subsets also exhibiting herniated discs, synovial cysts, and degenerative spondylolisthesis.

Tisseel does not reduce postoperative drainage, length of stay, and transfusion requirements for lumbar laminectomy with noninstrumented fusion versus laminectomy alone

BACKGROUND

Typically, fibrin sealants (FSs) and fibrin glues (FGs) are used to strengthen dural repairs during spinal surgery. In 2014, Epstein demonstrated that one FS/FG, Tisseel (Baxter International Inc., Westlake Village, CA, USA) equalized the average times to drain removal and length of stay (LOS) for patients with versus without excess bleeding (e.g. who did not receive Tisseel) undergoing multilevel laminectomies with 1-2 level noninstrumented fusions (LamF).[6].

METHODS

Here Tisseel was utilized to promote hemostasis for two populations; 39 patients undergoing average 4.4 level lumbar laminectomies with average 1.3 level noninstrumented fusions (LamF), and 48 patients undergoing average 4.0 level laminectomies alone (Lam). We compared the average operative time, estimated blood loss (EBL), postoperative drainage, LOS, and transfusion requirements for the LamF versus Lam groups.

RESULTS

The average operative times, EBL, postoperative drainage, LOS, and transfusion requirements were all greater for LamF versus Lam patients; operative times (4.1 vs. 3.0 h), average EBL (192.3 vs. 147.9 cc), drainage (e.g. day 1; 199.6 vs. 167.4 cc; day 2; 172.9 vs. 63.9 cc), average LOS (4.6 vs. 2.5 days), and transfusion requirements (11 LamF patients; 18 Units [U] RBC versus 2 Lam patients; 3 U RBC).

CONCLUSIONS

Utilizing Tisseel to facilitate hemostasis in LamF versus Lam still resulted in greater operative times, EBL, postoperative average drainage, LOS, and transfusion requirements for patients undergoing the noninstrumented fusions. Although Tisseel decreases back bleeding within the spinal canal, it does not reduce blood loss from LamF decorticated transverse processes.

Use of a haemostatic matrix does not reduce blood loss in minimally invasive total knee arthroplasty

BACKGROUND

Blood loss can increase morbidity and the risk of transfusion after total knee arthroplasty (TKA). This study evaluated the difference in blood loss between minimally invasive TKA performed with and without intra-articular use of a haemostatic matrix (Floseal®).

MATERIALS AND METHODS

We retrospectively compared matched pairs in two groups (76 patients in each group): one group received conventional haemostasis (with bovie electrocoagulation), the other group was treated with an intra-articular haemostatic matrix (HM) as an adjunct to electrocoagulation. The outcomes compared were haemoglobin (Hb) and haematocrit levels at days 2 and 4 after surgery as a surrogate for blood loss, transfusion rate, surgical time, preoperative and postoperative range of motion (ROM) at days 21 and 42 and length of stay (LOS) in hospital.

RESULTS

No differences were observed for Hb levels at day 2 or day 4 between men in the two groups. In women, however, the mean Hb at day 2 was 11.1 g/dL (SD 1.3) for TKA with HM and 12.0 g/dL (SD 0.9) for TKA without HM (p<0.001), while that at day 4 was 10.6 g/dL (SD 1.3) for TKA with HM and 11.4 g/dL (SD 1.2) for TKA without HM (p<0.001). The haematocrit was higher for TKA without HM at day 2 (p=0.001) and day 4 (p=0.008). The transfusion rate for TKA with HM was 2.6% and for TKA without HM 0% (p=0.497), while the mean surgical time was 93 minutes (SD 12) vs 87 minutes (SD 14), respectively (p=0.0055). There were no differences in preoperative or postoperative ROM at days 21 and 42 between the two groups. The LOS was longer for TKA with HM than for TKA without HM (4.5 days and 4 days, respectively, p=0.011) influenced by the longer stay for the transfused patients.

DISCUSSION

The present study showed that the use of Floseal had no effect on reducing either visible or hidden blood loss after TKA, as assessed by a drop in Hb or haematocrit and that hidden blood loss was more important in women treated with the HM.

Use of a Thrombin Fibrin Sealant in Reducing Blood Loss in Revision Hip Arthroplasty

We present a retrospective evaluation assessing the use of a novel fibrin sealant, Quixil^® (OMRIX Biopharmaceuticals S.A.) in reducing blood transfusions following revision total hip replacement surgery. Forty four patients underwent revision total hip replacement surgery using Quixil^®, while 45 patients underwent revision total hip replacement surgery without the use of Quixil^®. The duration of surgery and patient demographics were similar in both groups. Average blood loss was 1,010ml in the Quixil^® group versus 1,021ml in the non-Quixil group. The use of cell saver and intra-operative blood transfusion were similar in both groups. The mean pre-operative Haemoglobin was 13.0 g/dl in the Quixil^® group versus 12.4 g/dl in the non-Quixil group. The mean post-operative haemoglobin was 10.2 g/dl and 9.1 g/dl in the Quixil^® and non-Quixil groups respectively. There was no difference in the blood transfused post-operatively between the two groups. Total units of blood transfused in Quixil^®versus non-Quixil group were 60 verus 86. Total units of intra-operative blood transfused in Quixil^®versus non-Quixil group were 16 versus 23. The use of fibrin tissue adhesive in revision total hip arthroplasty seems to be an effective and reliable means to reduce blood-transfusion requirements and prevent post-operative decreases in hemoglobin.

Hemostasis and other benefits of fibrin sealants/glues in spine surgery beyond cerebrospinal fluid leak repairs

Background:

Fibrin sealants (FS)/glues (FG) are primarily utilized in spinal surgery to either strengthen repairs of elective (e.g., intradural tumors/pathology) or traumatic cerebrospinal fluid (CSF) fistulas. Here, additional roles/benefits of FS/FG in spine surgery are explored; these include increased hemostasis, reduction of scar, reduction of the risk of infection if impregnated with antibiotics, and its application to restrict diffusion and limit some of the major complications attributed to the controversial “off-label” use of bone morphogeneitc protein (rhBMP-2/INFUSE).

Methods:

We reviewed multiple studies, focusing not just on the utility of FS/FG in the treatment of CSF fistulas, but on its other applications.

Results:

FS/FG have been primarily used to supplement elective/traumatic dural closure in spinal surgery. However, FS/FG also contribute to; hemostasis, reducing intraoperative/postoperative bleeding/transfusion requirements, length of stay (LOS)/costs, reduced postoperative scar/radiculitis, and infection when impregnated with antibiotics. Nevertheless, one should seriously question whether FS/FG should be applied to prevent diffusion and limit major complications attributed to the “off-label” use of BMP/INFUSE (e.g., limit/prevent heterotopic ossification, dysphagia/respiratory decompensation, and new neurological deficits).

Conclusions:

FS/FG successfully supplement watertight dural closure following elective (e.g., intradural tumor) or traumatic CSF fistulas occurring during spinal surgery. Additional benefits include: intraoperative hemostasis with reduced postoperative drainage, reduced transfusion requirements, reduced LOS, cost, scar, and prophylaxis against infection (e.g., impregnated with antibiotics). However, one should seriously question whether FS/FG should be used to contain the diffusion of BMP/INFUSE and limit its complications when utilized “off-label”.

Tisseel utilized as hemostatic in spine surgery impacts time to drain removal and length of stay

Background:

Although fibrin sealants (FSs) and fibrin glues (FGs) are predominantly utilized to strengthen repairs of cerebrospinal fluid (CSF) fistulas (deliberate/traumatic) during spinal surgery, they are also increasingly utilized to achieve hemostasis. Here, we investigated whether adding Tisseel (Baxter International Inc., Westlake Village, CA, USA), utilized to address increased bleeding during multilevel lumbar laminectomies with non-instrumented fusions, would reduce or equalize the time to drain removal and length of stay (LOS) without contributing to infections or prolonging time to fusion.

Methods:

Prospectively, 39 patients underwent multilevel laminectomies and 1-2 level non-instrumented (in situ) fusions to address stenosis/olisthesis; 22 who demonstrated increased intraoperative bleeding received Tisseel, while 17 without such bleeding did not.

Results:

The 22 receiving versus 17 not receiving Tisseel, with similar clinical parameters, underwent comparable average multilevel laminectomies (4.36 and 4.25) and 1-2 level fusions (1.4 vs. 1.29 levels). As anticipated, for those receiving Tisseel, the average intraoperative estimated blood loss (EBL), total postoperative blood loss, and total perioperative transfusion requirements [red blood cells (RBC), fresh frozen plasma (FFP), platelets] were higher. However, Tisseel had the added benefit of equalizing the time to postoperative drain removal [e.g. 3.41 days (with) vs. 3.38 days (without)] and LOS [e.g. 5.86 days (with) vs. 5.82 days (without)] without increasing the infection rates (e.g. one superficial infection per group) or average times to fusion (e.g. 5.9 vs. 5.5 months).

Conclusions:

Adding Tisseel for increased bleeding during multilevel laminectomies/in situ fusions contributed to hemostasis by equalizing the average times to drain removal/LOS compared to patients without increased bleeding and not requiring Tisseel.

Is fibrin sealant effective and safe in total knee arthroplasty? A meta-analysis of randomized trials

The objective of this study was to evaluate the efficacy and safety of fibrin sealant in patients following total knee arthroplasty (TKA). A comprehensive literature search of the electronic databases PubMed, MEDLINE, Web of Science, and Cochrane Library for published randomized controlled trials (RCTs) was undertaken. The evidence base was critically appraised using a tool from the Cochrane Bone, Joint and Muscle Trauma Group. Eight RCTs involving 641 patients were included. The use of fibrin sealant significantly reduced postoperative drainage (weighted mean difference (WMD) -346, 95% confidence interval (CI) -496.29 to -197.54, P < 0.00001) and blood transfusions (risk ratio (RR) 0.47, 95% CI 0.35 to 0.63, P < 0.00001) and led to a significant improvement in the range of motion (WMD 16.59, 95% CI 6.92 to 26.25, P = 0.0008). However, using fibrin sealant did not significantly reduced total blood loss (WMD -305.25, 95% CI -679.44 to 68.95, P = 0.11). Regarding complications, there were no significant differences in any adverse events, fever, infection, or hematoma among the study groups. In conclusion, the present meta-analysis indicates that the use of fibrin sealant was effective and safe as a hemostatic therapy for patients with TKA.

Ten-year follow-up on Dutch orthopaedic blood management (DATA III survey)

INTRODUCTION

Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. This survey was conducted to assess the current use of perioperative blood-saving measures and to compare it with prior results.

MATERIALS AND METHODS

All departments of orthopaedic surgery at Dutch hospitals were sent a follow-up survey on perioperative blood-saving measures, and data were compared to the results of two surveys conducted 5 and 10 years earlier.

RESULTS

The response rate was 94 out of 108 departments (87%). Most departments used erythropoietin prior to hip and knee replacements at the expense of preoperative autologous blood donation. The use of intraoperative autologous retransfusion in revision hip (56 vs. 54%) as well as revision knee arthroplasty (26 vs. 24%), was virtually unchanged. Postoperative autologous retransfusion is still used by the majority of departments after both primary arthroplasty and revision of hip (58/53%) and knee (65/61%).

CONCLUSIONS

Currently, just as in 2007, the majority of Dutch orthopaedic departments uses erythropoietin, normothermia and postoperative autologous retransfusion with hip and knee arthroplasty. Intraoperative retransfusion is used mainly with hip revision arthroplasty. Other effective blood management modalities such as tranexamic acid have not been widely implemented.

Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty

INTRODUCTION

Reducing allogeneic blood transfusions remains a challenge in total knee arthroplasty. Patients with preoperative anemia have a particularly high risk for perioperative blood transfusions.

MATERIALS AND METHODS

176 anemic patients (Hb < 13.5 g/dl) undergoing total knee replacement were prospectively evaluated to compare the effect of a perioperative cell saver (26 patients), intraoperative fibrin sealants (5 ml Evicel, Johnson & Johnson Wound Management, Ethicon, Somerville, NJ) (45 patients), preoperative autologous blood donation (PABD) (21 patients), the combination of fibrin sealants and preoperative autologous blood donation (44) and no intervention (40 patients) on perioperative blood loss and transfusion requirements.

RESULTS

All protocols resulted in significant reduction of allogeneic blood transfusions. Transfusion rates were similar with the use of PABD (19%), Evicel (18%), and cell saver (19%), all significantly lower than the control group (38 %, p < 0.05). Combining Evicel with PABD resulted in significantly higher wastage of autologous units (p < 0.05) with no significant reduction in allogeneic transfusion rate (14%). The use of fibrin sealant resulted in a significant reduction of blood loss compared to the PABD group (603 vs. 810 ml, p < 0.005) as well as the control group (603 vs. 822 ml, p < 0.005).

CONCLUSIONS

While PABD proved to be the most cost-effective treatment option in anemic patients, fibrin sealants and cell saver show similar reduction in allogeneic transfusion rates compared to controls. The combination of fibrin sealants and PABD is not cost-effective and increases the number of wasted units.

Current state and use of biological adhesives in orthopedic surgery

Bone and tissue adhesives are common and beneficial supplements to standard methods of musculoskeletal tissue suture repair. Knowledge and development of biologically derived or inspired adhesives useful in orthopedic surgery are rapidly advancing. Recent literature demonstrates the increased adjunct or primary use of biological adhesives in the repair of musculoskeletal soft tissues, chondral fractures, and osteochondral fractures. Adhesives offer more benefits and enhancements to tissue healing than current fixation methods afford, including improved biocompatibility, resorbability, and non-immunogenicity. Further investigation is required to determine the extent of the role that these bioadhesives can play in orthopedic surgery. The largest group of biologically derived adhesives and sealants is fibrin sealants, which include first- and second-generation commercially available fibrin sealants, autologous fibrin sealants, and variants. Other groups include gelatin-resorcin aldehydes, protein-aldehyde systems, collagen-based adhesives, polysaccharide- based adhesives, mussel adhesive proteins, and various biologically inspired or biomimetic glues. Potential uses include applications in orthopedic-related blood conservation, arthroplasty, articular cartilage disorders, sports medicine, spine surgery, trauma, and tumors. The development of an adhesive with universal application is likely unfeasible, given the unique characteristics of various musculoskeletal tissues. However, the literature demonstrates the overall underuse of adhesives and indicates the rising probability of the development of a successful variety of bioadhesives for use in orthopedic surgery. As a result of reading this article, physicians should be able to: 1. Describe the difference between adhesives and sealants. 2. Recognize fibrin adhesives commonly used in practice today and identify other biological adhesives with rising potential. 3. Analyze how fibrin sealants work relative to fibrin and fibrinogen. 4. Identify anatomical areas and techniques in which fibrin sealants are used.

Bleeding disorders in orthopedic surgery

With increasing recognition of the complications related to coagulopathies, it is of paramount importance for all orthopedic surgeons to possess a basic knowledge of common bleeding disorders. The evaluation of the coagulopathic patient requires a careful history, physical examination, and laboratory evaluation. Bleeding disorders commonly include quantitative and qualitative platelet and coagulation factor disorders and coagulation inhibitors. The management of these coagulopathies that can be encountered in elective and nonelective practice is often ignored. With appropriate knowledge and a multidisciplinary approach with hematologists and cardiologists, surgeons can perform minor and major orthopedic procedures safely and effectively.

Limit allogeneic blood use with routine re-use of patient's own blood: a prospective, randomized, controlled trial in total hip surgery

BACKGROUND

There are risks related to blood incompatibility and blood-borne diseases when using allogeneic blood transfusion. Several alternatives exist today, one of which, used for autologous blood salvage perioperatively, is the Sangvia Blood Management System. This study was designed to investigate the efficacy of the system and to add data to previously reported safety results.

METHODOLOGY/PRINCIPAL FINDINGS

Two hundred sixteen patients undergoing primary or revision total hip arthroplasty (THA) were enrolled in this randomized, controlled, assessor-blinded multicenter study. Randomization was either autologous blood transfusion (Sangvia group) or no use of autologous blood (Control group), both in combination with a transfusion protocol for allogeneic transfusion. Patients were followed during hospital stay and at two months after discharge. The primary outcome was allogeneic blood transfusion frequency. Data on blood loss, postoperative hemoglobin/hematocrit, safety and quality of life were also collected. The effectiveness analysis including all patients showed an allogeneic blood transfusion rate of 14% in both groups. The efficacy analysis included 197 patients and showed a transfusion rate of 9% in the Sangvia group as compared to 13% in the Control group (95%CI -0.05-0.12, p = 0.5016). A mean of 522 mL autologous blood was returned in the Sangvia group and lower calculated blood loss was seen. 1095 mL vs 1285 mL in the Control group (95%CI 31-346, p = 0.0175). No differences in postoperative hemoglobin was detected but a lower hematocrit reduction after surgery was seen among patients receiving autologous blood. No relevant differences were found for safety parameters or quality of life.

CONCLUSIONS/SIGNIFICANCE

General low use of allogeneic blood in THA is seen in the current study of the Sangvia system used together with a transfusion protocol. The trial setting is under-powered due to premature termination and therefore not able to verify efficacy for the system itself but contributes with descriptive data on safety.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00822588.

Comparison of hemostatic matrix and standard hemostasis in patients undergoing primary TKA

Bleeding after total knee arthroplasty increases the risk of pain, delayed rehabilitation, blood transfusion, and transfusion-associated complications. The authors compared pre- and postoperative decreases in hemoglobin as a surrogate for blood loss in consecutive patients treated at a single institution by the same surgeon (J.L.C.) using conventional hemostatic methods (electrocautery, suturing, or manual compression) or a gelatin and thrombin-based hemostatic matrix during total knee arthroplasty. Data were collected retrospectively by chart review. The population comprised 165 controls and 184 patients treated with hemostatic matrix. Median age was 66 years (range, 28-89 years); 66% were women. The arithmetic mean ± SD for the maximal postoperative decrease in hemoglobin was 3.18 ± 0.94 g/dL for controls and 2.19 ± 0.83 g/dL for the hemostatic matrix group. Least squares means estimates of the group difference (controls-hemostatic matrix) in the maximal decrease in hemoglobin was 0.96 g/dL (95% confidence interval, 0.77-1.14 mg/dL; P<.0001). Statistically significant covariate effects were observed for preoperative hemoglobin level (P<.0001) and body mass index (P=.0029). Transfusions were infrequent in both groups. The frequency of acceptable range of motion was high (control, 88%; hemostatic matrix, 84%). In both groups, overall mean tourniquet time was approximately 1 hour, and the most common length of stay was 3 to 5 days. No serious complications related to the hemostatic agent were observed. These data demonstrate that the use of a flowable hemostatic matrix results in less reduction in hemoglobin than the use of conventional hemostatic methods in patient undergoing total knee arthroplasty.

Prospective randomized evaluation of a collagen/thrombin and autologous platelet hemostatic agent during total knee arthroplasty

The purpose of this study was to evaluate the effectiveness of a collagen/thrombin and autologous platelet hemostatic agent in preventing blood loss during primary total knee arthroplasty. This prospective, double-blinded, randomized study was designed to enroll a total of 100 patients. Patients were randomized 1:1 to either the treatment arm (standard hemostasis plus study product) or the control arm (standard hemostasis alone). Transfusion requirements, as determined by a blinded investigator using standardized criteria, were significantly lower in the treatment group (no blood transfusions) compared with the control group (5 transfusions; P = .007). These data support the addition of the study product to prevent blood transfusions after primary total knee arthroplasty.

Current concepts for the use of platelet-rich plasma in the foot and ankle

Platelet-rich plasma (PRP) injections have been used and studied since the 1970s. Its use has become more popularized over the last several years in the treatment of foot and ankle injuries. Platelets are a normal product found in the clotting cascade and inflammatory process of healing. They produce granules that release growth factors that promote healing. PRP works by increasing the concentration of platelets, thereby increasing the concentration of growth factors and increasing healing potential. PRP has an advantage over many tissue engineering products in that it is autologous. It has been studied and used for the treatment of tendon injuries, chronic wounds, ligamentous injuries, cartilage injuries, muscle injuries, and bone augmentation. The results from in vitro and in vivo studies in foot and ankle injuries are promising. The applications for treatment in the foot and ankle may be broader than once thought.

A rapid recovery program: early home and pain free

Enhancement of our perioperative pain management protocols has resulted in accelerated rehabilitation. At our facility, the majority of patients undergoing total and partial knee arthroplasty are treated with a single-shot spinal anesthetic consisting of a combination of bupivacaine and duramorph. The bupivacaine affords the immediate perioperative anesthetic while the duramorph results in sustained analgesia for a period of 12 to 24 hours. We use intra-articular injections delivered directly into the soft tissue of the knee. Our current intra-articular injection is 60 mL of 0.5% ropivacaine with 0.5 mg of epinephrine. In patients with a normal renal function, 30 mg of ketorolac is added. The injection is administered throughout all of the soft tissues in and around the knee. Prophylactic antiemetics are administered in the form of dexamethasone, ondansetron, and a scopolamine patch. The use of this perioperative anesthesia provides effective pain relief with no motor blockade. Patients are able to participate in physiotherapy within several hours of the operative procedure, performing active range of motion and ambulating with assistive devices. Patients with no significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately 2 weeks postoperatively. Additionally, all patients are treated with oxycodone, either preoperatively or within 2 hours of arrival to the floor postoperatively. Patients younger than 70 years are given 20 mg of oxycodone while those older than 70 years are given 10 mg of oxycodone. The oxycodone is continued for the first 24 hours of the hospital stay. Patients are then managed with oxycodone and hydrocodone. Length of stay has decreased and currently averages <2 days.