Effect of Hypovitaminosis D on Postoperative Pain Outcomes and Short-Term Health-Related Quality of Life After Knee Arthroplasty: A Cohort Study

Vitamin D may have an important role in pain perception. Inadequate vitamin D levels are associated with suboptimal recovery after surgery. However, the effects of hypovitaminosis D on postoperative pain-related outcomes and its impact on health-related quality of life after surgery are not well understood. The objective of this study was to determine the effects of hypovitaminosis D on postoperative pain-related outcomes and health-related quality of life at 3 months after knee arthroplasty.This was a longitudinal cohort study of 191 consecutive Hong Kong Chinese patients who were given patient-controlled morphine analgesia for up to 72 hours after 214 knee arthroplasties. Serum total 25-hydroxyvitamin D (25-OHD) concentration was assessed by liquid chromatography-tandem mass spectrometry. The primary outcomes were postoperative pain intensity at rest scores (0–72 h), Western Ontario and McMaster Universities (WOMAC) osteoarthritis index (pain, stiffness and function), and moderate-to-severe persistent pain (transformed WOMAC pain score of 0–75 at 3 months after knee arthroplasty; 0, extreme pain; 100, no pain). Group differences were analyzed using generalized estimating equation models and a logistic regression model.The prevalence of preoperative hypovitaminosis D (25-OHD <50 nmol/L) was 44% (95% confidence interval [CI]: 37%–51%). There were transient higher pain intensity scores in the moderate-to-severe hypovitaminosis D (25-OHD <30 nmol/L) group compared with the sufficient vitamin D group. Vitamin D status had no effect on total WOMAC index (P = 0.22). The incidence of moderate-to-severe persistent pain was 9% (95% CI: 6%–14%). Hypovitaminosis D increased the risk of moderate-to-severe persistent pain (adjusted odds ratio 2.64, 95% CI: 1.03–6.77).Preoperative hypovitaminosis D had subtle effects on pain intensity scores in the early postoperative period and is a risk factor for moderate-to-severe persistent pain after knee arthroplasty. Hypovitaminosis D was not associated with worse health-related quality of life at 3 months after knee arthroplasty.     

Increased Long-Term Cardiovascular Risk After Total Hip Arthroplasty: A Nationwide Cohort Study

Total hip arthroplasty is a common and important treatment for osteoarthritis patients. Long-term cardiovascular effects elicited by osteoarthritis or the implant itself remain unknown. The purpose of the present study was to determine if there is an increased risk of late cardiovascular mortality and morbidity after total hip arthroplasty surgery.A nationwide matched cohort study with data on 91,527 osteoarthritis patients operated on, obtained from the Swedish Hip Arthroplasty Register. A control cohort (n = 270,688) from the general Swedish population was matched 1:3 to each case by sex, age, and residence. Mean follow-up time was 10 years (range, 7–21).The exposure was presence of a hip replacement for more than 5 years. The primary outcome was cardiovascular mortality after 5 years. Secondary outcomes were total mortality and re-admissions due to cardiovascular events.During the first 5 to 9 years, the arthroplasty cohort had a lower cardiovascular mortality risk compared with the control cohort. However, the risk in the arthroplasty cohort increased over time and was higher than in controls after 8.8 years (95% confidence interval [CI] 7.0–10.5). Between 9 and 13 years postoperatively, the hazard ratio was 1.11 (95% CI 1.05–1.17). Arthroplasty patients were also more frequently admitted to hospital for cardiovascular reasons compared with controls, with a rate ratio of 1.08 (95% CI 1.06–1.11).Patients with surgically treated osteoarthritis of the hip have an increased risk of cardiovascular morbidity and mortality many years after the operation when compared with controls.     

Continuous Local Infiltration Analgesia for Pain Control After Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials

A total knee arthroplasty (TKA) has always been associated with moderate to severe pain. As more research is conducted on the use of continuous local infiltration analgesia (CLIA) to manage pain after a TKA, it is necessary to reassess the efficacy and safety of the TKA method. The purpose of this systematic review and meta-analysis of randomized controlled trials was to evaluate the efficacy and safety of pain control of CLIA versus placebo after a TKA.In January 2015, a systematic computer-based search was conducted in the Medline, Embase, PubMed, CENTRAL (Cochrane Controlled Trials Register), Web of Science, Google database, and Chinese Wanfang databases. This systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement criteria. The primary endpoint was the visual analog scale score after a TKA with rest or mobilization at 24, 48, and 72 hours, which represents the effect of pain control after TKA. The complications of infection, nausea, and whether it prolonged wound drainage were also compiled to assess the safety of CLIA. RevMan 5.30 software was used for the meta-analysis. After testing for publication bias and heterogeneity across studies, data were aggregated for random-effects modeling when necessary.Ten studies involving 735 patients met the inclusion criteria. The meta-analysis revealed that continuous infusion analgesia provided better pain control with rest at 24 hours (mean difference [MD] −12.54, 95% confidence interval [CI] −16.63 to 8.45), and with mobilization at 24 hours (MD −18.27, 95% CI −27.52 to 9.02) and 48 hours (MD −14.19, 95% CI −21.46 to 6.93). There was no significant difference with respect to the visual analog scale score at 48 hours (MD −6.15, 95% CI −13.51 to 1.22, P = 0.10) and 72 hours (MD −3.63, 95% CI −10.43 to 3.16, P = 0.29) with rest and at 72 hours with mobilization (MD −4.25, 95% CI −16.27 to 7.77, P = 0.49). However, CLIA increased the rate of infection (relative risk [RR] 3.16, 95% CI 1.18–8.50, P = 0.02) and the rate of nausea or vomiting (RR 0.60, 95% CI 0.37–0.96, P = 0.03). There were no significant differences in the length of hospital stay (MD −0.34, 95% CI −1.09 to 0.42, P = 0.38), deep venous thrombosis (RR 1.02, 95% CI 0.30 to 1.41, P = 0.99), or duration of surgery (MD 1.20, 95% CI −4.59 to 6.98, P = 0.69).On the basis of the current meta-analysis, CLIA was more efficacious for reducing postoperative pain than the placebo at 24 hours with rest and at 24 and 48 hours with mobilization, but it increased the risk of infection. However, CLIA did not prolong the length of hospital stay or the duration of surgery. There was also a higher heterogeneity of different analgesic drugs mixed and a high risk of selection bias in this analysis; therefore, more high-quality randomized controlled trials with standardized CLIA are necessary for proper comparisons of this technique with other methods.     

Trends and Determinants of Osteoporosis Treatment and Screening in Patients With Rheumatoid Arthritis Compared to Osteoarthritis

Objective

To profile osteoporosis (OP) care in patients with rheumatoid arthritis (RA) over the past decade.

Methods

Patients with RA or osteoarthritis (OA) were followed from 2003 through 2014. OP care was defined as receipt of OP treatment (with the exception of calcium/vitamin D) or screening (OPTS). Adjusted trends over followup, and the factors associated with OP care, were examined using multivariable Cox proportional hazards.

Results

OPTS was reported in 67.4% of 11,669 RA patients and in 64.6% of 2,829 OA patients during a median (interquartile range) 5.5 (2–9) years of followup. In patients for whom treatment was recommended by the 2010 American College of Rheumatology (ACR) glucocorticoid‐induced OP (GIOP) guidelines (48.4% of RA patients and 17.6% of OA patients), approximately 55% overall reported OP medication use. RA patients were not more likely to undergo OPTS compared to OA patients (hazard ratio 1.04 [95% confidence interval 0.94–1.15]). Adjusted models showed a stable trend for OPTS between 2004 and 2008 compared to 2003, with a significant downward trend after 2008 in both RA and OA patients. Factors associated with receipt of OP care in RA patients were older age, postmenopausal state, prior fragility fracture or diagnosis of OP, any duration of glucocorticoid treatment, and use of biologic agents.

Conclusion

Approximately half of RA patients for whom treatment was indicated never received an OP medication. OP care in RA patients was not better than in OA patients, and the relative risk of the application of this care has been decreasing in RA and OA patients since 2008 without improvement after the release of the 2010 ACR GIOP guideline.

     

A Randomized Trial of Acute Normovolemic Hemodilution Compared to Preoperative Autologous Blood Donation in Total Knee Arthroplasty

The value of acute normovolemic hemodilution (ANH) compared to preoperative autologous blood donation (PAD) in elective surgery is controversial. We therefore conducted a prospective, randomized study to compare these techniques in patients undergoing total knee arthroplasty. ANH patient underwent up to 4 units phlebotomy or to target hematocrit level of 28% after induction of anesthesia. PAD patients were asked to donate 1 (unilateral) or 2 (bilateral, revisions) units before admission. Mean baseline hematocrit levels were not different between ANH and PAD patients (40.6±4.1 vs. 38.4±3.4, p = 0.09). Eight (73%) of 11 patients undergoing bilateral revision procedures received a total of 22 allogeneic blood units, whereas only 3 (14%) of 21 patients undergoing primary, unilateral procedures received a total of 3 allogeneic units (p = 0.002). We found no differences in allogeneic blood transfusions between ANH and PAD cohorts for all (n = 32) patients (1.0±1.2 vs. 0.6±1.4, p = 0.45), for unilateral knee (n = 21) replacement (0.25±0.46 vs. 0.08±0.28, p = 0.29), or for bilateral/revision (n = 11) procedures (1.9±1.3 vs. 2.5±1.9, p = 0.53). We conclude that each technique is equally effective in reducing allogeneic blood exposure. Patients undergoing revision or bilateral knee arthroplasties require adjunctive therapy to autologous blood procurement to further reduce allogeneic blood exposure.