Does adding corticosteroids to periarticular injection affect the postoperative acute phase response after total knee arthroplasty?

BackgroundPeriarticular injection (PAI) can reduce pain and improve early outcomes following total knee arthroplasty (TKA). Although corticosteroid PAI has been reported to be safe and effective, investigations on the postoperative acute phase response (APR) are scarce.MethodsThis retrospective cohort study with propensity score matching investigated two groups of patients after TKA: the steroid group (n = 50) received an intraoperative corticosteroid PAI (methylprednisolone 40 mg); the non-steroid group (n = 50) did not receive the corticosteroid. To evaluate the APR, C-reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR) were determined preoperatively and on postoperative day (POD) 2, 4, 6, 14, and 28. A visual analogue scale (VAS) was used to measure pain on the night of surgery and on POD 1, 2, 4, and 6. Maximal flexion at discharge (POD 7), morphine equivalent dose (MED), and complications were also evaluated.ResultsThe steroid group showed significantly lower CRP levels on POD 2 (P < .05) and POD 4 (P < .05) but a higher CRP level on POD 6 (P < .05). However, ESR levels did not differ between the two groups in all measurements. Peak values in CRP and ESR in the steroid group (POD 4 and 6) appeared two days later compared with the non-steroid group (POD 2 and 4). The VAS pain score was significantly lower in the steroid group on POD 2 (P < .05). Maximal flexion on discharge, MED and complication rate were similar in the two groups.ConclusionsAdding a corticosteroid to the PAI following TKA attenuated the APR, and also provided significant pain relief.     

Comparison of peripheral nerve block with periarticular injection analgesia after total knee arthroplasty: A randomized,controlled study

BackgroundPain after total knee arthroplasty (TKA) is usually severe. Recently, the usefulness of local periarticular injection analgesia (PAI) and peripheral nerve block (PNB) has been reported. We report a prospective blinded randomized trial of PAI versus PNB in patients undergoing primary TKA, in accordance with the CONSORT statement 2010.MethodsA total of 210 patients undergoing TKA under spinal anesthesia were randomized to receive PNB group or PAI group. In the PNB group, femoral nerve block and sciatic nerve block were performed. In the PAI group, a special mixture containing ropivacaine, saline, epinephrine, morphine hydrochloride, and dexamethasone was injected into the periarticular soft tissue. Pain intensity at rest was assessed using a numerical rating scale (NRS: 0–10) after surgery. Use of a diclofenac sodium suppository (25 mg) was allowed for all patients at any time after surgery, and the diclofenac sodium suppository usage was assessed. The NRS for patient satisfaction at 48 hours after surgery was examined.ResultsThe average NRS for pain at rest up to 48 hours after surgery was low in both groups. Within 48 hours after surgery, the diclofenac sodium suppository usage was similar in both groups. There were no significant differences in the NRS for patient satisfaction in both groups.ConclusionsThe analgesic effects of PAI and PNB are similar. PAI may be considered superior to PNB because it is easier to perform.Level of EvidenceTherapeutic Level 1.     

Wiberg Type III patellae and J-sign during extension compromise outcomes of total knee arthroplasty without patellar resurfacing

BackgroundUnderstanding the risk factors associated with postoperative pain and worse outcome can guide surgeons on whether primary patellar resurfacing is warranted during total knee arthroplasty (TKA). The purpose of this study was to determine whether clinical scores and pain after TKA without patellar resurfacing are correlated with patellar shape and postoperative patellar position and kinematics.MethodsRadiographs as well as anterior knee pain according to the Visual Analogue Scale (pVAS) were collected pre- and postoperatively for 100 knees aged 68 ± 7.7 years that received uncemented TKA without patellar resurfacing. At a minimum follow-up of 12 months the Forgotten Joint Score (FJS), the Oxford Knee Score (OKS) as well as the flexion range of motion and the presence of J-sign during active extension were recorded. Uni- and multivariable linear regression analyses were performed to determine associations between the collected clinical scores and patient demographic and radiographic data.ResultsPostoperative OKS (79 ± 14.4) was worse for Wiberg Type III patellae (β = − 11.4, P = .020, compared with Type II). Anterior pVAS (2 ± 2) was greater in knees with J-sign during extension (β = 2.8, P < .001). None of the other radiographic measurements (patellar tilt, congruence angle and lateral patellar displacement) were correlated with postoperative OKS or anterior pVAS.ConclusionIncongruent patellar shape (Wiberg Type III) is associated with worse clinical scores, and abnormal kinematics (J-sign) with increased pain after TKA without patellar resurfacing. The authors therefore recommend routine resurfacing for Wiberg Type III patellae, though further studies are required to confirm whether resurfacing truly improves clinical scores and pain in this subgroup.     

Effect of ultrasound-guided selective sensory nerve blockade of the knee on pain management compared with periarticular injection for patients undergoing total knee arthroplasty: A prospective randomized controlled trial

BackgroundUltrasound-guided selective sensory nerve blockade (SSNB) of the knee, including an adductor canal block (ACB), anterior femoral cutaneous nerve block, and infiltration between the popliteal artery and posterior capsule of the knee may provide effective motor-sparing knee analgesia for total knee arthroplasty (TKA). We hypothesized that the SSNB would manage pain better on ambulation 24 hours postoperatively compared to periarticular infiltration (PAI), when combined with postoperative continuous ACB.MethodsSeventy-two patients undergoing elective TKA under spinal anesthesia were randomly assigned to either SSNB (SSNB group) or intraoperative PAI (PAI group). All patients received postoperative multimodal analgesia, including continuous ACB. The primary outcome was pain on ambulation 24 hours postoperatively. Secondary outcomes included rest and dynamic numerical rating scale pain score, intravenous morphine requirement, functional performance measures, adverse events, satisfaction, and length of stay.ResultsThere was no difference in pain score during movement between the groups (mean difference −0.48 [−1.38 to 0.42], p = 0.3) and other immediate overall pain scores 24 hours postoperatively. Patients in the SSNB group had significantly lower intravenous morphine requirement than the PAI group for 48 hours postoperatively (0 [0, 0] vs. 0 [0, 2]; p = 0.008). There was no intergroup difference in the performance-based measures, satisfaction, and length of stay.ConclusionsThe SSNB did not provide superior postoperative analgesia, or improvement in immediate functional performance. However, it may result in lower opioid consumption postoperatively when compared with the intraoperative PAI.     

Radiographic severity,extent and pattern of cartilage loss are not associated with patient reported outcomes before or after total knee arthroplasty in end-stage knee osteoarthritis

BackgroundThe aim of this study was to determine if radiographic severity, extent or pattern of knee osteoarthritis was associated with pain and function before total knee arthroplasty (TKA) or improvement therein one year after TKA.MethodsA prospective study of 259 patients undergoing unilateral TKA for Kellgren-Lawrence (KL) grade ≥ 3 knee osteoarthritis was conducted: mean age 69.8 ± 9.7 (44–91); mean BMI 31.0 ± 5.8 (17–52); 152/259 (58.7%) female. Preoperative radiographs were assessed using the KL and Ahlback systems. Preoperatively and 1 year postoperatively patients completed Oxford Knee Scores, VAS-Pain and EQ-5D scores. Full thickness cartilage loss was recorded intraoperatively.ResultsMedian radiographic severity was Ahlback 2, KL 4: 51/259 (19.7%) hypertrophic; 23/259 (8.8%) atrophic. Neither Ahlback nor Kellgren-Lawrence OA grade was associated with OKS, VAS Pain or EQ-5D prior to TKA (p > 0.05). The extent and pattern of cartilage loss did not affect preoperative PROMs. Radiographic OA severity, compartment involvement, and pattern of cartilage loss were not significantly associated with PROMs or improvements therein following TKA (p > 0.05). Hypertrophic OA was associated with less pain before TKA (difference 6.8, 0.23–13.9 95%CI, p = 0.044), and worse improvement in OKS following TKA (difference −3.41, −6.8 to −0.05 95%CI, p = 0.047). Better preoperative OKS and hypertrophic OA were independently associated with poorer improvement in OKS 1 year following TKA (R² = 0.208).ConclusionProvided at least one compartment has KL grade ≥ 3 changes, further radiographic severity, pattern or extent of cartilage loss did not affect PROMs before or after TKA: multicompartmental was no worse than unicompartmental disease.     

The accuracy of component alignment in custom cutting blocks compared with conventional total knee arthroplasty instrumentation: Prospective control trial

BackgroundThe purpose of this study was to assess whether custom cutting blocks improve accuracy of component alignment compared to conventional TKA instrumentation.MethodsEighty primary TKA patients were enrolled in an open-label randomized prospective clinical trial and were divided into two groups, 40 custom cutting blocks and 40 conventional TKA instrumentations. The primary outcome was prosthetic alignment with respect to mechanical axis and epicondylar axis. Secondary outcomes included operative time, 24-hour postoperative blood loss and hemoglobin at discharged.ResultsThere were no statistical significant differences in the postoperative mechanical axis between the custom cutting blocks group and conventional TKA group, (95% vs. 87.5% within 3° of neutral mechanical alignment, p = 0.192). The average rotational alignment was statistically significantly different in the custom cutting blocks group (1.0° ± 0.6° vs. 1.6° ± 1.8° external rotation from epicondylar axis, p < 0.001). There were statistical significant differences in operation time between custom cutting blocks group and conventional group, skin to skin [57.5 ± 2.3 min vs. 62.1 ± 1.5,p < 0.001]. We found an improvement in group 1 compared with group 2 regarding the proportion of patients with postoperative blood loss within 24 h.ConclusionsCustom cutting blocks technique was a surgical procedure which provided better accuracy in rotational alignment but no statistical differences in mechanical axis, less operative time and reduced blood loss than the conventional TKA instrumentation in the majority of patients.     

The use of pedobarographic analysis to evaluate movement patterns in unstable total knee arthroplasty: A proof of concept study

BackgroundDefinition and clinical diagnosis of instability in TKA is challenging. Sensitive and objective biomechanical tools to aid diagnosis are currently lacking. This proof-of-concept study evaluates the use of pressure mat analyses to identify abnormal biomechanical loading patterns associated with TKA instability within an outpatient clinical setting.MethodsTwenty participants were examined: 10 patients with suspected unilateral TKA instability and 10 healthy controls. Participants underwent bilateral stance and gait tests measuring time and limb loading pressure parameters. Gait was divided into three phases: heel strike, mid-foot and toe off. Pressure recordings are expressed relative to bodyweight. Between-limb loading discrepancies were calculated in TKA patients and controls, and these differences were then compared between groups. Statistical significance was accepted at p < 0.05.ResultsTKA patients consistently offloaded pressure away from the operated limb, whereas healthy controls exhibited more even limb loading throughout bilateral stance (p < 0.05). TKA patients exhibited greater discrepancy in overall step contact time between limbs (−0.09 s ± 0.16 s; p = 0.016) compared to controls (0.06 s ± 0.08 s; p = 0.04). Post-hoc tests showed significant between-group differences during midfoot (−0.04 s ± 0.07 s; p = 0.03) and toe-off (0.05 s ± 0.14 s; p = 0.013). Between-group differences in limb loading discrepancy were evident at heel strike (−9.24% ± 2.11%; p = 0.0166) and toe-off (−10.34% ± 5.51%; p = 0.0496).DiscussionPedobarographic measurements demonstrated differences in mechanical loading patterns in patients with TKA instability compared to healthy controls during functional tasks and warrants further investigation. This may prove to be a useful clinical diagnostic tool in identifying patients that would benefit from revision surgery or physical therapy.     

Use of bone wax reduces blood loss and transfusion rates after total knee arthroplasty

BackgroundUnnecessary costs and complications can be reduced by minimizing blood loss and allogeneic blood transfusion in cases of total knee arthroplasty (TKA). This study evaluated the effectiveness of bone wax in reducing blood loss and transfusion rates after TKA.MethodsA total of 674 consecutive TKAs performed for degenerative osteoarthritis were retrospectively reviewed. Propensity score-matching and inverse probability of treatment weighting analyses were performed for demographics, comorbidities, use of medications, preoperative laboratory findings and radiologic prosthetic coverage of osteotomy surface. In the bone wax group, bone wax (2.5 g) was applied to the uncovered bone section around the prostheses along with the topical administration of tranexamic acid, whereas hemostasis was achieved in the control group with the topical administration of tranexamic acid. Intergroup comparisons of estimated blood loss, decreases in hemoglobin (Hb) levels, and transfusion rates were performed.ResultsThe mean estimated blood loss and volume of postoperative drainage were reduced in the bone wax group. The maximum decreases in Hb levels on postoperative days 1, 3, 5, and 7 were 1.8 ± 0.7 ml, 2.5 ± 0.8 ml, 2.7 ± 0.8 ml, and 2.8 ± 0.8 ml in the bone wax group and 2.1 ± 1.0 ml, 3.0 ± 1.2 ml, 3.1 ± 1.1 ml, and 3.2 ± 1.1 ml in the control group, respectively. The postoperative transfusion rates decreased markedly from 8.8% to 2.0% when bone wax was used.ConclusionsThe use of bone wax significantly reduced blood loss, decreased Hb levels, and the risk of transfusion.Level of evidence: Level III, Therapeutic studies.     

Patellar cartilage loss does not affect early outcomes of total knee arthroplasty performed without patella resurfacing

BackgroundThe aim of this study was to compare the outcomes and cost economics of TKA without patella resurfacing in patients with and without patellar cartilage loss.MethodsProspective case control study of 209 consecutive patients undergoing TKA without patella resurfacing. Patella cartilage status was documented intra-operatively: 108 patients had patella cartilage loss (mean age 70 ± 9.7, mean BMI 31 ± 6.2, 72 (67%) female) and 101 control patients did not (age 68 ± 9.2, BMI 31 ± 5.6, 52 (51%) female). The primary outcome measure was Oxford Knee Score (OKS) improvement at one year. Secondary outcomes included OKS, EQ-5D, anterior knee pain (AKP), Kujala scores and reoperation at 2–4 years. The cost to prevent secondary patella resurfacing was calculated.ResultsThere were more women in the patella cartilage loss group (67% Vs 51%, p = 0.037), but no other preoperative characteristics differed. There was no difference in OKS improvement between those with and without patella cartilage loss at 1 year (mean difference −1.03, −3.68 to 1.62 95%CI, p = 0.446) or 2–4 years (mean difference 1.52, −1.43 to 4.45 95%CI, p = 0.310). At 2–4 years there was no difference in AKP (14/87 with vs 17/80 without, p = 0.430) nor Kujala score (mean difference 2.66, −3.82 to 9.13 95%CI, p = 0.418). Routine patella resurfacing would have cost £58,311 to prevent one secondary resurfacing.ConclusionThere was no difference in OKS, anterior knee pain, reoperation or Kujala scores up to 2–4 years between patients with and without patellar cartilage loss following TKA without patella resurfacing. Resurfacing for this indication would not have been a cost effective intervention.     

Surgical epicondylar axis is not orthogonal to the femoral mechanical knee axis in valgus knees with primary osteoarthritis: Three-dimensional analysis according to knee coronal alignment in 112 patients

BackgroundDuring total knee arthroplasty (TKA), most surgeons align the femoral component along the surgical epicondylar axis (SEA) considering it as orthogonal to the femoral mechanical axis. However, it is still unclear how SEA coronal alignment varies according to the native coronal knee alignment. The main goal of this study was to analyze the SEA orientation according to the native coronal knee morphotype.MethodsA total of 112 patients underwent a three-dimensional (3D) -planning-based TKA. The SEA was then determined by locating the epicondyles on 3D models. The 3D femoral and tibial mechanical axes were marked and the femoral (FMA) and tibial (TMA) mechanical angles were measured. The native HKA angle was measured as FMA + TMA. The SEA orientation angles were measured in the coronal (SEA-α) and axial (SEA-β) plane. SEA orientation was compared between the valgus, neutral, and varus knees.ResultsThe mean SEA-α angle was 90.2 ± 3° and the mean axial SEA-β angle was 92.2 ± 1.3°. The SEA-α angle was significantly higher in the valgus group compared with the neutral group (92.3 ± 2.9°, 90 ± 2.9°, P = 0.0009) whereas there was no significant difference in the SEA-α angle between the varus and the neutral group (89.7 ± 2.3°, 90 ± 2.9°, P = 0.32).ConclusionsIn contrast to the neutral and varus knees, the SEA was not orthogonal to the femoral mechanical axis in patients undergoing TKA for primary osteoarthritis. Our results suggest adapting the coronal alignment of the femoral component during TKA, while maintaining an average 2° valgus in valgus knees. By contrast, with varus and neutral knees, our data support the use of a mechanical alignment.     

Efficacy and safety of single-dose local infiltration of analgesia in total knee arthroplasty: A meta-analysis of randomized controlled trials

PurposeTo examine the efficacy and safety of single-dose local infiltration of analgesia (LIA) for post-operative pain relief in total knee arthroplasty (TKA) patients.MethodsA systematic electronic literature search (up to Aug 2013) was conducted to identify the RCTs that address the efficacy and safety of single-dose LIA in the pain management after TKA. Subgroup analysis was conducted to determine changes of visual analog score (VAS) values at six different postoperative time points. Weighted mean differences or relative risks with accompanying 95% confidence intervals were calculated and pooled using a random effect model.ResultsEighteen trials involving 1858 TKA patients met the inclusion criteria. The trials were liable to medium risk of bias. The VAS values at postoperative 2 h, 4 h, 6 h, 12 h, 24 h, and 48 h per patient were significantly lower in the LIA group than in the placebo group, and the former group also had less morphine consumption and better early functional recovery including range of motion, time to straight leg raise and 90° knee flexion than the latter group. No significant difference in length of hospital stay or side effects was detected between the two groups.ConclusionsThe current evidence shows that the use of single-dose LIA is effective for postoperative pain management in TKA patients, with satisfactory short-term safety. More high-quality RCTs with long-term follow-ups are required for examining the long-term safety of single-dose LIA.Level of evidenceI, II     

The influence of obesity on clinical outcomes following primary total knee arthroplasty: A prospective cohort study

BackgroundThe aim of this study was to evaluate the influence of obesity on patients' function, pain, and complications following primary total knee arthroplasty (TKA) with an enhanced-recovery program.MethodsA total of 157 patients were enrolled into a prospective study and assigned into one of three groups on the basis of their body mass index (BMI): normal (BMI 18.0–24.9 kg/m²), overweight (BMI 25.0–29.9 kg/m²), or obese (BMI ≥ 30.0 kg/m²). The primary outcome was knee range of motion (ROM) on postoperative day (POD) 3, 15, 30, and 90, and secondary outcomes were visual analog scale (VAS) on POD 1, 2, 3, 15, 30, and 90, length of stay, and complications.ResultsThe ROM of patients in the obese group on POD 3 was higher than in the normal (104.4 ± 8.5 vs. 98.9 ± 8.9, P = .010) and overweight (104.4 ± 8.5 vs. 97.7 ± 7.8, P = .001) groups. Similarly, the VAS in the obese group at rest on POD 1 was lower than in the normal (2.0 ± 0.7 vs. 2.2 ± 0.6, P = .043) and overweight (2.0 ± 0.7 vs. 2.3 ± 0.6, P = .010) groups. In addition, the incidence of complications did not differ significantly among the three groups, but the length of hospital stay in the obese group was longer (P = .027).ConclusionsObesity may not affect patients' function and pain, and may not increase the incidence of complications following primary TKA. Obese patients may obtain satisfactory functional rehabilitation outcomes, but with a longer duration of rehabilitation.     

Clinical usefulness and safety in the early phase after a newly designed rotating-platform total knee arthroplasty: A prospective multicentre cohort study with a 2-year follow up

BackgroundThis study aimed to assess the clinical results and safety of a newly designed rotating-platform posterior-stabilised total knee arthroplasty (TKA) in the early postoperative phase, within 2 years of follow up.MethodsThis prospective, multicentre cohort study included 100 consecutive patients who underwent rotating-platform posterior-stabilised (PS) TKA (Vanguard PSRP). After excluding dropouts, 93 patients were analysed. The objective Knee Society Score (KSS)-2011, subjective KSS-2011, knee range of motion, EuroQol 5 Dimension index, complications, and survival rates were assessed before TKA and at 6 months, 1 year, and 2 years postoperatively. The scores at each time-point were compared, and the survival rate was assessed with revision as the endpoint. To demonstrate non-inferiority, the clinical outcomes of patients who underwent rotating-platform PS TKA were compared with those collected retrospectively from 50 patients who underwent fixed-PS TKA (Vanguard PS), defined as the control group.ResultsAll clinical outcomes at the final follow up significantly improved compared with their preoperative values (P < 0.001). The objective KSS-2011 was 90.0 ± 8.2 points, subjective KSS-2011 satisfaction was 30.7 ± 8.6 points, expectation was 10.4 ± 2.1 points, and functional activity was 74.0 ± 18.5 points at 2 years postoperatively. Complications included knee dislocation in one patient and surgical site infection in one patient. The survival rate was 99% at 2 years postoperatively. Clinical outcomes, complications, and survival rates of newly designed TKA were not statistically different compared with the control group.ConclusionThe newly designed rotating-platform PS TKA showed good clinical results and suitable safety during the early postoperative phase in this prospective multicentre cohort study.     

Prospective sequential comparison of femoral roll-back between cruciate-retaining and posterior-stabilized total knee arthroplasty using an intra-operative sensor

BackgroundImplant design and surgical techniques affect postoperative knee kinematics in total knee arthroplasty (TKA). This study aimed to compare femoral roll-back between cruciate-retaining (CR) and posterior-stabilized (PS) TKA in the same knee by objectively quantifying the contact point kinematics of the tibiofemoral joint using a sensor.MethodsIn the present prospective study, we used an intraoperative sensor to compare medial and lateral roll-back during 0-120° knee flexion in 33 knees that underwent CR and PS TKA. We also examined the relationship between mediolateral balance and the lateral-to-medial roll-back ratio. We defined the contact percentage position as the vertical length to the contact point divided by the anteroposterior length of the tibial plate.ResultsThe roll-back percentage following PS TKA (19.8 ± 5.1%) was significantly higher than that after CR TKA in both the medial (19.8 ± 5.1% versus 7.1 ± 2.5%, P < 0.001) and lateral (26.8% ± 3.8% versus 18.7 ± 3.8%, P < 0.001) compartments. The medial contact pressure at 90° was significantly correlated with the increased lateral-to-medial roll-back ratio in both CR and PS TKA (both P < 0.001).ConclusionPS TKA resulted in a higher percentage of femoral roll-back in the medial and lateral compartments than CR TKA. CR TKA caused a higher lateral-to-medial roll-back ratio compared to PS TKA. To reproduce medial pivot knee motion similar to that of a normal knee, the medial soft tissue needed to be balanced more tightly than the lateral soft tissue during TKA. These findings provide some clinical evidence of TKA design selection and proper mediolateral balancing for successful TKA.     

Does intraoperative transfusion during total knee arthroplasty reduce the need for transfusion after surgery?: A preliminary retrospective cohort study

ObjectivesAfter total knee arthroplasty (TKA), many patients experience anemia due to blood loss. To prevent postoperative anemia and allogeneic blood transfusion after TKA, we used prophylactic allogeneic or autologous blood transfusion intraoperatively. This study evaluated the effects of prophylactic transfusion during TKA.Materials and methodsThis retrospective cohort study included 579 patients receiving scheduled unilateral TKA. We allocated the patients into three groups, the prophylactic allogeneic transfusion (Group AL), prophylactic autologous transfusion (Group AT), and no prophylactic transfusion with intra-articular tranexamic acid administration (Group C) groups. After propensity score matching, we compared the rate of postoperative allogeneic blood transfusions until three days after TKA, postoperative hemoglobin and hematocrit levels until four days after TKA, and the side effects in each groups.ResultsThe postoperative allogeneic blood transfusion rates were statistically higher in group AL and AT than in group C (18.2% and, 18.9% vs 2.3%, respectively; P < 0.000). The postoperative hemoglobin and hematocrit levels were statistically lower in group Auto than in group C (P < 0.0001), but the levels in group AL were not different from those of group C (P = 0.493 vs. P = 0.384 respectively). In addition, the side effects were statistically higher in group AL and AT than in group C.ConclusionProphylactic intra-operative transfusions did not reduce the rates of allogeneic transfusions and produced more side effects and hypotension after surgery than intra-articular tranexamic acid administration with no prophylactic transfusion in patients undergoing TKAs.     

Characteristics of the descending genicular artery blood flow velocity in patients with knee osteoarthritis

BackgroundIn patients with knee osteoarthritis (KOA), the descending genicular artery (DGA) showed abnormal angiogenesis. However, the non-invasive assessment method of DGA remains unclear. The aim of this study was to clarify the characteristics of blood flow velocity of the DGA in patients with KOA and to examine the factors involved in the changes.MethodsThe KOA group included 22 knees of 22 patients with KOA (4 males, 18 females; mean age, 72.3 ± 7.5 years) and the control group included 22 knees (4 males, 18 females; mean age, 71.3 ± 5.4 years) of 22 healthy adults. The peak systolic blood flow velocity (PSV) in each group was measured using ultrasonography. The KOA group was classified into the effusion group and the non-effusion group based on observed effusion, and the PSV was compared between the two groups. The relationships between PSV and suprapatellar bursa intracavitary distance, pain, femorotibial angle, Japanese Knee Osteoarthritis Measure were also investigated.ResultsThe PSV in the KOA group (51.5 ± 12.9 cm/s) was significantly higher than that in the control group (29.3 ± 4.4 cm/s) (P < 0.01). In the KOA group, PSV in the effusion group (55.5 cm/s (51.2–59.4 cm/s)) was significantly higher than that in the non-effusion group (39.1 cm/s (35.1–44.4 cm/s)) (P < 0.01). The PSV was positively and significantly correlated with both suprapatellar bursa intracavitary distance (r = 0.81: P < 0.01) and pain (r = 0.48: P < 0.05).ConclusionsThe PSV measurement in the DGA is useful for the evaluation of non-invasive synovitis of patients with KOA.     

The effect of music and skin contact with the newborn on pain and anxiety during episiotomy repair in primiparous women: A double-blind randomized controlled study

ObjectiveTo show that music medicine and skin contact with the newborns can reduce pain and anxiety during episiotomy repair.DesignDouble-blind randomized controlled trialSettingThe study was conducted between April and July 2020 at the private Medipol Nisa Hospital.ParticipantsA total of 150 primiparous pregnant women over 20 years of age who underwent vaginal delivery with episiotomyInterventionsParticipants were randomized into the music medicine, skin contact with the newborn, and control groups (with no treatment). After episiotomy repair (with the designated treatment or no treatment), the State Trait Anxiety Inventory and Visual Analog Scale were used to assess anxiety and pain, respectively.Main outcome measuresPain and anxiety experienced after episiotomy repair in the treatment and control groups.ResultsWomen in both treatment groups (music medicine and skin-to-skin contact) had significantly lower anxiety and pain levels than those in the control group. In particular, music medicine significantly reduced pain in comparison to skin contact with the newborn (VAS 2 3.92 ± 1.46 vs. 5.42 ± 1.73, respectively, VAS 3 2.64 ± 1.63 vs. 5.14 ± 1.77, respectively, VAS 4 1.38 ± 1.46 vs. 4.14 ± 2.04, respectively, p < 0.05). Thus, music medicine is more effective than skin-to-skin contact in reducing the pain experienced during episiotomy repair, but both treatments were equally effective in reducing anxiety (35.30 ± 6.47 vs. 36.82 ± 9.71 vs. 49.22 ± 16.95, respectively, p < 0.05).ConclusionBoth of these nonpharmacological treatments can be used along with analgesics and anxiolytics for the treatment of pain and anxiety during episiotomy repair.     

Clinical efficacy of adductor canal block in medial open wedge high tibial osteotomy

BackgroundTo evaluate the effect of adductor canal block (ACB) on short-term postoperative outcomes in patients who underwent medial open-wedge high tibial osteotomy (MOWHTO) compared to that of a placebo.Methods35 patients who underwent unilateral MOWHTO between 2017 and 2019 were prospectively reviewed and randomly divided into two groups: 19 patients who received a single-shot ACB and 16 patients who received a saline injection (a placebo group). Primary outcomes were (1) pain measured using the visual analog scale and range of motion, (2) patient satisfaction, (3) postoperative need for additional opioids, (3) quadriceps strength (the time to straight leg raising [SLR]), (4) clinical outcomes, and (5) complications.ResultsThe pain score was lower in the ACB group than in the placebo group in the first 12 h (p = 0.04). ACB did not exhibit significantly less quadriceps strength weakness postoperatively. There was no statistical difference in the time to SLR (23.5 ± 17.7 h in ACB vs. 27.6 ± 11.4 in placebo, p = 0.520). The opioid consumption rate within postoperative 12 h was significantly decreased after ACB (16.7% in ACB, 70% in placebo, p = 0.017). The proportion of patients with more than 5 opioid injections within 72 h postoperatively was lower in the ACB group (8.3% in ACB, 50% in placebo, p = 0.043). Both groups did not show any localized and systemic complications.ConclusionACB following MOWHTO exhibited better outcomes than a placebo with respect to opioid consumption with no changes in the quadriceps strength and complications.Level of EvidenceII, Prospectively comparative study     

Conforming patellar button design improves outcome of total knee arthroplasty

BackgroundPatellar resurfacing is commonly performed during total knee arthroplasty (TKA), and the patellar button design can vary within a TKA implant. Implant design is known to affect patella kinematics, contact mechanics, and ultimately the outcome of TKA. The aim of this study was to compare the patient-reported outcomes of TKA with either a conforming (CP) or medialized dome (MD) patellar component.MethodsThe study was a prospective cohort study of 100 TKAs performed between December 2015 and August 2017. We compared a consecutive series of 50 TKA subjects with a CP, with the previous 50 TKA subjects with an MD patella. The primary outcome measure was difference in Knee Injury and Osteoarthritis Score (KOOS) at 12 months. Other patient-reported outcome measures included EQ5D as a general health measure, and patient satisfaction.ResultsThere was no significant difference in baseline characteristics, KOOS, or EQ5D between the two groups. At 12 months, the CP Group had a higher mean KOOS function score (87 vs. 80, P = 0.04), and greater patient satisfaction (98% vs. 82% satisfied, P = 0.009) compared with the MD group. The CP Group had significantly lower frequency of pain with level walking, less difficulty with stairs, and lower mean EQ5D mobility at 12 months compared with the MD group.ConclusionsTKA performed using a conforming patella has superior results over a medialized dome patellar component for KOOS function, patient satisfaction, walking pain, stair performance, and mobility at 12 months postoperatively. The differences observed with the change in patellar design may be unique to this prosthesis.     

Postoperative bleeding adversely affects total knee arthroplasty outcomes in hemophilia

BackgroundHemophilic arthropathy can result in severe degenerative arthritis and functional limitations in the knees of relatively young patients. Total knee arthroplasty (TKA) provides pain relief and gain of function in advanced-stage hemophilic arthropathy cases. However, little is known about the long-term effects of early major postoperative bleeding (MPOB) in people with hemophilia (PWH). The aim of this study was to evaluate the effects of early MPOB on the final functional outcome, complications, and implant survival of TKA in a single-center hemophilia cohort.MethodPWH who underwent TKA between 1998 and 2019 in a single center were reviewed. Demographic data, clinical data, and radiographic images were evaluated. Hospital for Special Surgery (HSS), Knee Society Score (KSS), and Knee Society Function Score (KSS-F) scores were used to determine function. Patients with early bleeding complications (wound dehiscence, ecchymosis, hemarthrosis, hematoma formation, prolonged or recurrent bleeding attacks) were defined as the bleeding group. Patients who did not experience these complications were assigned to the control group. The bleeding group was compared with controls. Survival of the primary arthroplasty was analyzed by Kaplan–Meier curves.ResultsForty-five TKAs in 29 patients were included in the study. TKA led to an increase in the mean range of motion from 46.08° to 84.59° (P < 0.01). HSS scores increased from 48.33 preoperatively to 82.67 postoperatively (P < 0.01). There were improvements in both KSS and KSS-F scores from 34.22 and 53.3 preoperatively to 82.00 and 84.63 (P < 0.01), respectively. Ten patients (10 TKAs) (34%) experienced major bleeding during the postoperative period. Six of these patients had moderate hemophilia, and four had severe hemophilia. Three of these patients had hemarthroses (10.2%), one patient had a hematoma (3.4%), one patient had hemorrhagic bullae formation (3.4%), and five had excessive/prolonged bleeding from the wound (17%). The bleeding group (34%) had significantly worse HSS (63.78 vs 92.75, P < 0.001), KSS (61.78 vs 93.25, P < 0.001), and KSS-F (60.71 vs 96.25, P = 0.005) scores compared with controls. Preoperative and postoperative flexion contractures were positively correlated (+0.33, P = 0.003). One of the patients with postoperative hemarthrosis also had an accompanying transient common peroneal nerve palsy, and one patient (3.4%) had a periprosthetic fracture. Three knees (6.6%), two of whom were in the bleeding group, developed periprosthetic infections. Four knees (8.8%) in three patients underwent revision surgery, and two knees (4.4%) ended up in arthrodeses. Kaplan–Meier analysis revealed a mean survival duration of 17.04 years for the bleeding group and 22.15 years for the control group (P = 0.83). Survival rates were 80.0% for the bleeding group and 96.4% for the control group (P = 0.83).ConclusionsIn this study, MPOB after TKA in PWH was common and led to significantly worse function. MPOB after TKA in PWH was associated with a higher rate of complications and lower survival rates, although the differences were not statistically significant. Efforts must be made to avoid MPOB after TKA in PWH.