Early Recovery Following Total and Unicompartmental Knee Arthroplasty Assessed Using Novel Patient-Reported Measures

BackgroundThe early postoperative recovery period following unicompartmental (UKA) and total knee arthroplasty (TKA) is an important area for research with increasingly sensitive metrics and new technologies. This study uses 2 recently developed patient-reported scores to compare the recovery following UKA and TKA.MethodsTwo consecutive cohorts of 37 UKAs and 33 TKAs completed the Oxford Arthroplasty Early Recovery Score (OARS) and the Oxford Arthroplasty Early Change Score (OACS) on days 1, 2, 3, 7, 14, and week 6. The Short Form-36 version 2 was also completed on weeks 1, 2, and 6. Improvements within cohorts and comparisons between cohorts were assessed.ResultsFor both UKA and TKA the speed of recovery was rapid early on and then progressively decreased. At all time points, the UKA cohort reported similar or significantly better scores than the TKA cohort. The overall OARS (P < .001) showed that UKA recovered, shown as improvement on the OARS, 2-3 times faster than TKA. OARS subscales demonstrated that UKA had better Function/Mobility (P = .003) particularly early in the recovery, and better Nausea/Feeling Unwell (P < .001) and Fatigue/Sleep (P = .009) later in the recovery. UKA also had less pain at 2 weeks (P = .03). There was no significant difference between UKA and TKA OACS. UKA had significantly better scores in 3 of the 8 Short Form-36 domains, with the largest difference being in Role-Emotional (P = .003).ConclusionThe OARS is useful for the assessment of postoperative recovery. This study provides direct evidence that recovery following UKA is better and 2-3 times faster than following TKA. All differences may be explained by the less invasive nature of UKA.     

No Difference Unicompartmental Knee Arthroplasty for Medial Knee Osteoarthritis With or Without Anterior Cruciate Ligament Deficiency: A Systematic Review and Meta-analysis

BackgroundA functional intact anterior cruciate ligament (ACLI) is considered to be a prerequisite for unicompartmental knee arthroplasty (UKA). However, UKA has been shown to have good clinical efficacy in ACL-deficient (ACLD) knees at 3 to 10 years follow-up. Therefore, the role of ACLD in UKA remains controversial, and more evidence is needed to clarify the role of ACLD in UKA.MethodsPubMed, the Web of Science, EMBASE, and Cochrane Central were queried for articles comparing the results of the ACLD and ACLI groups after UKA. Outcomes of interest included the Tegner Activity Scale, the Oxford Knee Score (OKS), postoperative slope of the implant (PSI), the Knee Injury and Osteoarthritis Outcomes Score (KOOS), the Lysholm score, and revision rate. There were eight studies included. The mean age was 66 years (range 49 to 87 year old) and the mean follow-up time was 6.9 years (range 1.3 to 16.6 years). There was baseline comparability regarding mean age, duration of follow-up, and body mass index (P > .5) between the ACLD and ACLI groups.ResultsThe ACLD and ACLI groups had improved postoperative functional indicators, and that postoperative revision rate (mean difference [MD], 1.24; 95% confidence interval [CI], 0.75 to 2.04; P = .4), Tegner score (MD, ?0.1; 95% CI, ?0.26 to 0.05; P = .19), and Lysholm score (95% CI, ?2.46 to 7.32; P = .33) were similar between the groups, with no significant differences; however, the ACLD groups had significantly better KOOS Activities of Daily Living scores, with a significant difference (MD, 4.53; 95% CI, 1.75 to 7.3; P = .001). Also, there were no significant differences between two groups in the PSI, OKS, KOOS.ConclusionACL deficiency is not always a contraindication for UKA. With correct patient selection, UKA could be considered for medial knee osteoarthritis with ACL deficiency without antero-posterior instability, especially these people over 60 years of age.     

Long-Term Functional Outcomes and Quality of Life at Minimum 10-Year Follow-Up After Fixed-Bearing Unicompartmental Knee Arthroplasty and Total Knee Arthroplasty for Isolated Medial Compartment Osteoarthritis

BackgroundThe aim of this study is to compare the long-term functional outcome and quality of life between total knee arthroplasty (TKA) and fixed-bearing unicompartmental knee arthroplasty (UKA) for the treatment of isolated medial compartment osteoarthritis.MethodsBetween 2000 and 2008, a total of 218 patients underwent primary UKA at our tertiary hospital. A TKA group was matched through 1:1 propensity score matching and adjusted for age, gender, body mass index, preoperative knee flexion, and function scores. All patients had medial compartment osteoarthritis. The patients were assessed with the range of motion, Knee Society Knee Score and Knee Society Function Score, Oxford Knee Score, Short Form-36 physical component score (PCS) and mental component score preoperatively, at 6 months, 2 years, and 10 years. Patients’ satisfaction, expectation fulfillment, and minimal clinically important difference were analyzed.ResultsThere were no differences in baseline characteristics between groups after propensity score matching (P > .05). UKA had greater knee flexion at all time points. Although the Knee Society Function Score was superior in UKA by 5.5, 3, and 4.3 points at 6 months, 2 years, and 10 years, respectively (P < .001), these differences did not exceed the minimal clinically important difference (Knee Society Knee Score 6.1). There were no significant differences in the Oxford Knee Score and Short Form-36 physical component score/mental component score. At 10 years, similar proportions of UKA and TKA were satisfied (90.8% vs 89.9%, P = .44) and had expectation fulfillment (89.4% vs 88.5%, P = .46). Between 2 and 10 years, all function scores deteriorated significantly for both groups (P < .01).ConclusionUKA and TKA are excellent treatment modalities for isolated medial compartment osteoarthritis, with similar functional outcomes, quality of life, and satisfaction at 10 years.     

Does Unicompartmental Knee Replacement Offer Improved Clinical Advantages Over Total Knee Replacement in the Treatment of Isolated Lateral Osteoarthritis? A Matched Cohort Analysis From an Independent Center

BackgroundThe purpose of this study is to compare the functional and radiographic results, perioperative complications, satisfaction rate, and mid-term survivorship after unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) for the treatment of lateral compartmental knee osteoarthritis (LCKO).MethodsBetween March 2007 and September 2017, we identified 35 patients with primary TKAs and 121 patients with lateral UKAs (LUKAs) for LCKO with a minimum follow-up of 2 years (mean 5.3 years, range 2-12.4). The matched variables were age, gender, operation side, body mass index, American Society of Anesthesiologist grade, initial diagnosis, osteoarthritis grade in lateral compartment, and follow-up time. All patients were assessed using the Oxford Knee Score, Hospital for Special Surgery score, range of motion, length of hospital stay, satisfaction, and complications. Survivorship of UKA and TKA implants was also compared.ResultsAt last follow-up, LUKA had a significantly better postoperative Oxford Knee Score, Hospital for Special Surgery score, range of motion, shorter length of hospital time, and higher satisfaction rate than matched TKA group. There were significant differences regarding patellar tendon injury (P = .043), superficial wound infection (P = .028), patellar snapping or impingement (P = .047), and stiffness (P < .001). Five-year survivorships free from revision were similar in both groups (99.2% vs 97.1%, P = .347).ConclusionLUKA for LCKO demonstrated more favorable 5-year results in comparison with TKA. Furthermore, LUKA achieved comparable mid-term survivorship and was less likely to suffer from wound infection and knee stiffness, although not overall surgical complications.     

Predictors of Satisfactory Outcomes With Fixed-Bearing Lateral Unicompartmental Knee Arthroplasty: Up to 7-year Follow-Up

BackgroundThere is little literature available examining factors that may predict functional recovery after lateral unicompartmental knee arthroplasty (UKA). The purpose of this study was to report short to mid-term effectiveness and evaluate predictors of better outcome following lateral UKA.MethodsWe retrospectively reviewed 248 patients (260 knees) who underwent lateral UKA from January 2013, with a mean 5-year follow-up. The primary outcome measures comprised the Hospital for Special Surgery (HSS) score and patient satisfaction. Multivariate regression analyses were implemented to investigate associations between these factors with a satisfactory outcome. Implant survival was estimated by Kaplan-Meier analysis.ResultsComplete follow-up was available for 186 patients (198 knees). At last follow-up, the HSS scores were changed from 52.1 (range, 38-80) preoperatively to 85.6 (range, 61-98) (P < .001), The OKS improved from 22.8 (range, 16-32) preoperatively to 42.7 (range, 30-47) postoperatively (P < .01). The 5-year survival was 99.5%. The multivariate analysis showed that the following factors tended to obtain a satisfactory outcome: higher proportion of ASA class I (P < .001), diagnosis of primary OA (P = .007), postoperative limb alignment (P = .007), and higher preoperative HSS score (P = .019). Patients with valgus 9°-12° reported the highest HSS scores among different subgroups (P < .001).ConclusionFollowing lateral UKA, postoperative outcomes were satisfactory in patients with lower ASA scores, diagnosis with primary OA, higher preoperative HSS scores and those with postoperative valgus alignment. It is important to understand these correlations to help appropriate patient selection to obtain optimal function after lateral UKA.     

Mild Valgus Alignment After Lateral Unicompartmental Knee Arthroplasty Led to Lower Functional Results and Survivorship at Mean 8-Year Follow-Up

BackgroundIn medial unicompartmental knee arthroplasty (UKA), the best results and the highest survivorship are found by mild undercorrection of varus deformities. In lateral UKA, the desirable amount of valgus undercorrection has not yet been determined. The purposes of this study were to present the results of a consecutive series of lateral UKAs and to investigate the effect of postoperative limb alignment on them.MethodsA total of 161 lateral UKA were reviewed. Outcomes studied included range of motion (ROM), Knee Society Score (KSS), University of California Los Angeles Activity Score, Tegner Activity Scale, Forgotten Joint Score, visual analogue scale (VAS) for pain, and survivorship. Patients were divided into two groups according to postoperative alignment: group A (hip-knee-ankle ≥184°, 79 UKA) and group B (hip-knee-ankle <184°, 82 UKA).ResultsAt a mean follow-up of 8 years (range, 2-18), ROM (P < .01); KSS-C (P < .01); KSS-F (P < .01); VAS (P < .01) improved from baseline. No differences were noted in postoperative ROM, VAS, University of California Los Angeles, Tegner Activity Scale, and Forgotten Joint Score between groups. Group A showed higher postoperative clinical and functional KSS (P < .01) and higher survivorship (96.2 versus 91.5%, P = .01) than group B.ConclusionMild valgus alignment (3° or less) after lateral UKA is linked to lower clinical and functional scores and lower survivorship compared to moderate valgus (over 4°) at mean 8-year follow-up. More undercorrection of the coronal deformity in lateral UKA compared to medial UKA is desirable to get the best results.     

Patient-Reported Outcome Measures are not a Valid Proxy for Patient Satisfaction in Total Joint Arthroplasty

BackgroundPatient-reported outcome measures (PROMs) are increasingly used as quality benchmarks in total joint arthroplasty. The objective of this study is to investigate whether PROMs correlate with patient satisfaction, which is arguably the most important and desired outcome.MethodsOur institutional joint database was queried for patients who underwent primary, elective, unilateral total joint arthroplasty. Eligible patients were asked to complete a satisfaction survey at final follow-up. Correlation coefficients (R) were calculated to quantify the relationship between patient satisfaction and prospectively collected PROMs. We explored a wide range of PROMs including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form-12, Oxford Hip Score, Knee Society Clinical Rating Score (KSCRS), Single Assessment Numerical Evaluation, and University of California Los Angeles activity level rating.ResultsIn general, there was only weak to moderate correlation between patient satisfaction and PROMs. Querying the absolute postoperative scores had higher correlation with patient satisfaction compared to either preoperative scores or net changes in scores. The correlation was higher with disease-specific PROMs (WOMAC, Oxford Hip Score, KSCRS) compared to general health (Short Form-12), activity level (University of California Los Angeles activity level rating), or perception of normalcy (Single Assessment Numerical Evaluation). Within disease-specific PROMs, the pain domain consistently carried the highest correlation with patient satisfaction (WOMAC pain subscale, R = 0.45, P < .001; KSCRS pain subscale, R = 0.49, P < .001).ConclusionThere is only weak to moderate correlation between PROMs and patient satisfaction. PROMs alone are not the optimal way to evaluate patient satisfaction. We recommend directly querying patients about satisfaction and using shorter PROMs, particularly disease-specific PROMs that assess pain perception to better gauge patient satisfaction.     

Unicompartmental Knee Arthroplasty Patients Have Lower Joint Awareness and Higher Function at 5 Years Compared to Total Knee Arthroplasties: A Matched Comparison

BackgroundThe purpose of this study was to evaluate postoperative outcomes at minimum 5-year follow-up in patients following unicompartmental knee arthroplasty (UKA) compared to a matched cohort of total knee arthroplasty (TKA) patients.MethodsPatients who had primarily medial compartment osteoarthritis (OA) who met criteria for medial UKA underwent TKA or medial UKA between 2014 and 2015 at a single institution, matched for age, sex, and body mass index. There were 127 UKAs in 120 patients and 118 TKAs in 116 patients included with minimum 5-year follow-up (range, 6 to 8). Mean age was 69 years (range, 59 to 79) and 71 years (range, 62 to 80) in the UKA and TKA groups, respectively (P = .049).ResultsPatients who underwent UKA had significantly higher mean (±SD) Forgotten Joint Scores (87 ± 20 versus 59 ± 34, P < .001); higher Knee Society Scores (88 ± 14 versus 75 ± 21, P < .001); and lower Numeric Pain Rating Scores (0.8 ± 1.6 versus 1.9 ± 2.2, P < .001). Survivorship free from all-cause revision was 96% (95% CI = 93%-99%) and 99% (95% CI = 97%-100%) at 5 years for TKA and UKA, respectively (P = .52). There were 8 both component revisions in the TKA group within 5 years from the date of surgery and 2 UKA conversions to TKA after 5-year follow-up.ConclusionPatients who have medial compartment OA and underwent UKA had significantly lower joint awareness, decreased pain, improved function, and higher satisfaction compared to matched TKA patients at minimum 5-year follow-up while maintaining excellent survivorship.     

Preoperative Flexion Contracture Does Not Compromise the Outcomes and Survivorship of Medial Fixed Bearing Unicompartmental Knee Arthroplasty

BackgroundDespite the expanding indications for unicompartmental knee arthroplasty (UKA), the classic indication that limits flexion contracture to <5° in fixed bearing UKA excludes most patients with arthritic knees and has not been challenged in modern literature. This study compared the clinical outcomes between patients with severe flexion contracture and controls undergoing UKA.MethodsEighty seven medial fixed bearing UKAs performed in patients with severe (≥15°) flexion contracture were matched 1:1 with 87 controls without flexion or recurvatum deformity (−5°<extension<5°) using propensity scores to control for age, sex, BMI, Charlson comorbidity index, ASA class, and baseline patient-reported outcome measures (PROMs). Perioperative outcomes were recorded. Range of motion, Knee Society Score, Oxford Knee Score, SF-36, and patient satisfaction were assessed at 6 months and 2 years. Survivorship was recorded at mean 11.5 ± 3.2 years.ResultsPreoperative knee extension in the control and contracture groups was 0.9° ± 1.9° and 18.0° ± 3.5° (P < .001), respectively, whereas flexion was 122.8° ± 27.9° and 120.6° ± 13.6° (P = .502). The contracture group had poorer Knee Society functional (P = .023) and SF-36 physical score (P = .010) at 6 months. However, there was no difference in PROMs at 2 years. A similar proportion achieved the minimal clinically important difference for each PROM and was satisfied with surgery. Range of motion remained poorer in the contracture group and a higher percentage had residual contractures (P < .001). Ten-year survivorship was 94% and 97% in the control and contracture groups, respectively (P = .145).ConclusionAlthough patients with severe flexion contractures had a poorer range of motion and postoperatively, these patients attained comparable PROMs, satisfaction rates, and mid-term survivorship after UKA.Level of EvidenceIII, therapeutic study.     

Postoperative Outcomes Following Total Hip and Knee Arthroplasty in Patients with Pain Catastrophizing,Anxiety, or Depression

BackgroundThe relationship among pain catastrophizing, emotional disorders, and total joint arthroplasty (TJA) outcomes is an emerging area of study. The purpose of this study is to examine the association of these factors with 1-year postoperative pain and functional outcomes.MethodsA prospective cohort study of preoperative TJA patients using the Pain Catastrophizing Scale and Hospital Anxiety and Depression Scale (HADS-A/HADS-D) was conducted. Postoperative outcomes included Visual Analog Scale (VAS) pain, Oxford, Harris Hip (HHS) and Knee Society (KSS) scores. Median regression was used to assess the pattern of relationship among preoperative clinically relevant catastrophizing (CRC) pain, abnormal HADS, and 1-year postoperative outcomes.ResultsWe recruited 463 TJA patients, all of which completed 1-year follow-up. At 1 year, CRC-rumination (adjusted median difference 1; 95% confidence interval [CI] 0.31-1.69, P = .005) and abnormal HADS-A (adjusted median difference 1; 95% CI 0.36-1.64, P = .002) were predictors of VAS pain, CRC magnification a predictor of HHS/KSS (adjusted median difference 1.3; 95% CI 5.23-0.11, P = .041), and abnormal HADS-A a predictor of Oxford (adjusted median difference 3.68; 95% CI 1.38-5.99, P = .002). CRC patients demonstrated inferior VAS pain (P = .001), Oxford (P < .0001), and HHS/KSS (P = .025). Abnormal HADS patients demonstrated inferior postoperative VAS (HADS-A, P = .025; HADS-D, P = .030) and Oxford (HADS-A, P = .001; HADS-D, P = .030). However, patients with CRC experienced significant improvement in VAS, Oxford, and HHS/KSS (P < .05) from preoperative to 1 year. Similarly, patients with abnormal HADS showed significant improvement in VAS pain and HHS/KSS (P < .05).ConclusionTJA patients who are anxious, depressed, or pain catastrophizing have inferior preoperative and postoperative pain and function. However, as compared to their preoperative status, clinically significant improvement can be expected following hip/knee arthroplasty.     

Preoperative Bone Marrow Edema Negatively Impacts 10-Year Outcomes After Unicompartmental Knee Arthroplasty

BackgroundThe purpose of this study was to investigate the association between the extent of subchondral bone marrow edema (BME), as classified by magnetic resonance imaging, and intermediate to long-term outcomes after unicompartmental knee arthroplasty (UKA) for medial compartment osteoarthritis.MethodsWe enrolled 150 knees (144 patients) that underwent fixed-bearing UKA between April 2003 and December 2014 with a minimum follow-up of 5 years; the mean overall follow-up duration was 10 years (range, 5-18 years). We divided the patients into 2 groups based on the presence or absence of preoperative BME. Patients were also subdivided into 4 groups according to their BME scores determined by the magnetic resonance imaging Osteoarthritis Knee Score method. Clinical outcomes were assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score. Furthermore, survival rates and relevant risk factors that affect joint survivorship were analyzed.ResultsThe groups with BME demonstrated significantly worse postoperative WOMAC pain and Forgotten Joint Scores at the final follow-up than the group without BME (all P < .05). We also found significant differences among the scores of groups with different BME grades (all P < .05). Post hoc analysis demonstrated differences between groups 1 and 2, 1 and 3, 1 and 4, and 2 and 4 (all P < .05) with a significant correlation between postoperative clinical outcomes and the extent of BME (r = 0.430 [WOMAC pain], r = ?0.342 [Forgotten Joint Score]; P < .05). The survival rate was 95.4% for a mean period of 10 years for the UKAs, and the UKA survival was not associated with the presence of BME (P = .232; log-rank test).ConclusionAt a mean of 10 years, preoperative BME negatively impacted the clinical outcomes, especially pain, after UKA. However, UKA contributed to excellent survival rates for the same duration of follow-up, regardless of BME severity. Although this study does not provide any evidence that preoperative BME should be identified as a contraindication, evaluation of BME can provide crucial information about the expected outcomes.     

Operative Duration and Short-Term Postoperative Complications after Unicompartmental Knee Arthroplasty

BackgroundProlonged operative duration is an independent risk factor for postoperative complications in many orthopedic procedures ranging from shoulder arthroscopy to total hip and knee arthroplasties. It has not been well studied in unicompartmental knee arthroplasty (UKA). The purpose of this study is to assess the effect of operative duration on complications after UKA.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program registry, we identified all primary unilateral UKAs from 2005 to 18. Patients were divided into three cohorts based on the operative duration: < 90 minutes, between 90 and 120 minutes, and >120 minutes. Baseline patient and operative demographics (age, gender, etc.) and thirty-day complications were compared using bivariate analysis. Multivariate analysis was used to assess the independent effect of operative duration on postoperative outcomes after adjusting for differences in baseline characteristics.ResultsWe identified 11,806 patients who underwent primary UKA from 2005 to 18. There was no difference in the “any complication” rate between cohorts. However, operative duration >120 minutes was associated with a significantly higher likelihood of reoperation (odds ratio [OR] 2.02, 95% confidence interval [CI]: 1.15-3.57, P = .015), non–home discharge (OR: 2.14, CI: 1.65-2.77, P < .001), surgical site infection (OR: 1.76, CI: 1.03-3.01, P = .038), and blood transfusions (OR: 3.23, CI: 1.44-7.22, P = .004) when compared with operative duration <90 minutes. There was no difference in mortality rates.ConclusionIncreased operative duration greater than 2 hours in primary UKA is associated with an increased risk of non–home discharge, surgical site infection, reoperation, and blood transfusion.     

Intravenous Dexamethasone Injection Reduces Pain From 12 to 21 Hours After Total Knee Arthroplasty: A Double-Blind,Randomized, Placebo-Controlled Trial

BackgroundPain after total knee arthroplasty (TKA) affects postoperative recovery and patient satisfaction. The analgesic benefits of corticosteroids have not been well studied. We, therefore, investigated the analgesic effects of intravenous (IV) dexamethasone (DEX) in patients undergoing a TKA.MethodsThis was a randomized, double-blind, placebo-controlled trial of 0.15 mg/kg of IV DEX vs saline placebo in unilateral TKA. Fifty patients/arm were recruited. Primary outcomes were pain level, determined by a visual analog scale, and the amount of morphine consumption (mg) ≤48 hours post-TKA. Secondary outcomes were rates of nausea and vomiting, C-reactive protein concentrations, and functional outcomes.ResultsThe DEX group had a significantly lower mean visual analog scale score both at rest and during motion at 12, 15, 18, and 21 hours (P < .05). At 21 hours, the mean difference (Δ) in pain at rest was −11 points (95% confidence interval [CI], −21 to −2 points; P = .02) while the mean difference in pain during motion was −15 points (95% CI, −25 to −5 points; P = .004). The DEX group also had lower rates of nausea and vomiting: 29/50 (58%) vs 42/50 (84%) (P = .008) and lower mean C-reactive protein level: 89 vs 167, Δ = −78 mg/L (95% CI, −100 to −58 mg/L, P < .0001). There were no significant differences in mean morphine consumption by 48 hours, modified Western Ontario and McMaster University Osteoarthritis Index scores, and range of motion of the knee at 3-month follow-up (P > .05).ConclusionIV DEX relieves postoperative pain between 12 to 21 hours after TKA and may be a useful adjunct for controlling pain in patients undergoing TKA.     

Computer-Assisted Kinematic and Mechanical Axis Total Knee Arthroplasty: A Prospective Randomized Controlled Trial of Bilateral Simultaneous Surgery

BackgroundRandomized controlled trials of kinematic alignment (KA) and mechanical alignment (MA) in primary total knee arthroplasty (TKA) have to date demonstrated at least equivalence of KA in terms of clinical outcomes. No trial of bilateral TKA has been conducted so patient preference for one technique over the other is unknown.MethodsForty-one participants underwent computer-assisted bilateral TKA. The outcome measures were as follows: (1) joint range of motion and functional scores including the KOOS, the KOOS JR, Oxford Knee Score, and the Forgotten Joint Score at a minimum of 2 years; (2) preference and perception of limb symmetry; (3) intraoperative alignment data; (4) release and gap balance data; and (5) postoperative radiographic joint angles.ResultsThere were no significant differences with respect to flexion range (P = .970) or functional scores (mean KOOS, P = .941; KOOS JR, P = .685; Oxford Knee Score, P = .578; FJS, P = .542). Significantly more participants who favored one knee preferred their KA TKA (P = .03); however, half of the patients had no preference and the overall numbers were small. Only 3 participants perceived any limb asymmetry (P < .001). More releases were required in the MA group (P = .018). Standing hip-knee-ankle angle means and frequency distributions were similar (P = .097 and P = .097, respectively).ConclusionClinical outcomes were equivalent at 2 years. Significantly more participants preferred their KA joint. Fewer releases were required using a KA technique. Participants were visually insensitive to modest hip-knee-ankle angle asymmetry.Level of EvidenceLevel 1.     

Combination Effect of High-Dose Preoperative and Periarticular Steroid Injection in Total Knee Arthroplasty. A Randomized Controlled Study

BackgroundPostoperative pain remains a major barrier to a patient’s recovery after total knee arthroplasty (TKA). Periarticular corticosteroids in local infiltration analgesics (LIA) and high-dose intravenous corticosteroids have individually shown to improve pain control after TKA. However, potential interactions between them have not been investigated.This study aims to evaluate any combination effect of both routes of corticosteroids in TKA.MethodsThis is a double-blinded, paired, randomized controlled trial involving 1-stage bilateral TKAs. All received 16 mg of dexamethasone intravenously. One knee was randomized to receive LIA with 40 mg of triamcinolone, while the other knee receives LIA without corticosteroids.For each patient, one knee was affected by intravenous steroids only, while the other was under the combined effect of intravenous and periarticular steroids (IVPAS).Knee pain, Southampton wound scores, and functional knee scores (Knee Society Knee Score and Oxford Knee Scores) were compared between knees of the same patient.ResultsForty-six patients (92 TKAs) were included. IVPAS knees showed significantly lower visual analog scale scores from day 1 to 6 weeks (P < .05) and a larger range of movement from day 2 to 4 (P < .05). IVPAS knees achieved active straight leg raise earlier than intravenous steroids (1.6 vs 2.3 days, P < .05).No differences in Southampton wound scores and functional knee scores for up to 1 year.ConclusionCombining intravenous and periarticular corticosteroids improved pain control and recovery after TKA with no increase in wound complications up to 1 year.     

Perioperative Systemic Dexamethasone Reduces Length of Stay in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BackgroundThe objective of this review is to examine the effect of perioperative systemic corticosteroids at varying doses and timings on early postoperative recovery outcomes following unilateral total knee and total hip arthroplasty. The primary outcome was length of stay (LOS).MethodsA systematic review and meta-analysis of randomized controlled trials was performed. MEDLINE, EMBASE, and Cochrane Library databases were searched from inception to June 1, 2020. Studies comparing the outcome of adult patients receiving a systemic steroid to patients who did not receive steroids were included.ResultsSeventeen studies were included, incorporating 1957 patients. Perioperative corticosteroids reduced hospital LOS (mean difference [MD] = ?0.39 days, 95% confidence interval [CI] ?0.61 to ?0.18). A subsequent dose of corticosteroid at 24 hours further reduced LOS (MD = ?0.33, 95% CI ?0.55 to ?0.11). Corticosteroids resulted in reduced levels of pain on postoperative day (POD) 0 (MD = ?1.99, 95% CI ?3.30 to ?0.69), POD1 (MD = ?1.47, 95% CI ?2.15 to ?0.79), and POD2. Higher doses were more effective in reducing pain with activity on POD0 (P = .006) and 1 (P = .023). Steroids reduced the incidence of PONV on POD1 (log odds ratio [OR] = ?1.05, 95% CI ?1.26 to ?0.84) and POD2, with greater effect at higher doses (P = .046). Corticosteroids did not increase the incidence of infection (P = 1.000), venous thromboembolism (P = 1.000), or gastrointestinal hemorrhage (P = 1.000) but were associated with an increase in blood glucose (MD = 5.30 mg/dL, 95% CI 2.69-7.90).ConclusionPerioperative corticosteroids are safe, facilitate earlier discharge, and improve patient recovery following unilateral total knee arthroplasty and total hip arthroplasty. Higher doses (15-20 mg of dexamethasone) are associated with further reductions in dynamic pain and PONV, and repeat dosing may further reduce LOS.     

Comparison of Long-Term Survival Analysis Between Open-Wedge High Tibial Osteotomy and Unicompartmental Knee Arthroplasty

BackgroundTo compare unicompartmental knee arthroplasty (UKA) and open-wedge high tibial osteotomy (OWHTO) in a long-term follow-up propensity score matching analysis.MethodsPatients who underwent UKA or OWHTO for unilateral medial unicompartmental osteoarthritis (OA) between 2004 and 2010 were included. The ROM, HSS score, KS score, WOMAC score, forgotten joint score, OA progression in patellofemoral and lateral compartments, and survivorship were compared within ten years of follow-up between 67 UKA and 67 OWHTO patients after propensity score matching for age, gender, body mass index, range of motion, and osteoarthritis (OA) grade.ResultsAt the last follow-up, there were no significant differences between the two groups in clinical outcomes, but the WOMAC score showed better results after UKA (13.1 in UKA vs 18.9 in OWHTO, P = .011). The OA progression also showed no significant difference between the two groups. After a 10-year follow-up, the survival rate was higher in UKA patients (96.2%) than in OWHTO patients (87.7%), with no statistical difference (P = .06).ConclusionUKA showed better clinical outcomes and OA progressions than OWHTO. The survival rate presented a superiority of 8.5% for the UKA group in the 10-year follow-up, without significant difference.     

开放楔形胫骨高位截骨与单髁置换治疗膝关节内侧间室骨关节炎疗效的Meta分析

目的:系统评价开放楔形胫骨高位截骨(OWHTO)与单髁置换(UKA)治疗膝关节内侧间室骨关节炎的疗效。方法:按照Cochran协作网制定的检索策略进行检索,计算机检索Medline,Pubmed,EMbase,Cochrane Library,中国生物医学数据库,中文科技期刊数据库,万方数据库,手工检索相关的中英文骨科杂志和会议论文,检索时间截止为2018年3月。纳入OWHTO和UKA治疗膝关节内侧骨性关节炎的对照研究,对文献质量进行评价,对文献报道的术后膝关节功能、术后并发症、术后全膝关节置换术(TKA)翻修率、术后疼痛等数据进行提取,采用RevMan 5.0软件对数据进行Meta分析。结果:纳入符合标准的文献共8篇,共675例患者。Meta分析结果显示,OWHTO组与UKA组在术后膝关节HSS评分、膝评分、功能评分、Lysholm评分差异无统计学意义(P=0.32,P=0.87,P=0.22,P=0.53),OWHTO组术后关节活动度优于UKA组,差异有统计学意义(P=0.009);两组术后并发症及术后TKA翻修率差异无统计学意义(P=0.81,P=0.23)。两组患者术后膝关节疼痛无差异。结论:在治疗符合手术指征的膝关节内侧间室骨关节炎时,采用OWHTO可获得与UKA相似的膝关节评分、术后并发症和术后TKA翻修率,但是OWHTO术后关节活动度更好。     

Serratus anterior plane block reduces the prevalence of chronic postsurgical pain after modified radical mastectomy: A randomized controlled trial

Study objectiveTo determine whether ultrasound-guided serratus anterior plane block (SAPB) is associated with decreased prevalence of chronic postsurgical pain (CPSP) after modified radical mastectomy.DesignRandomized, double-blind, placebo-controlled study.SettingUniversity hospital.PatientsWe enrolled 198 patients aged 18–65 years with American Society of Anesthesiologists physical status I to II, undergoing unilateral modified radical mastectomy.InterventionsPatients were randomly allocated to receive SAPB with 30 ml of 0.5% ropivacaine (SAPB group) or 0.9% normal saline (Control group).MeasurementsThe primary outcome was the prevalence of CPSP three months after surgery. Secondary outcomes were area under the curve of the numeric rating scale pain scores over 24 h, postoperative 24-h morphine consumption, quality of recovery, length of post-anesthesia care unit stay, postoperative nausea and vomiting, dizziness, SAPB-related adverse events, the prevalence of CPSP at six months, and pain-related function at three and six months.Main resultsPreoperative SAPB with 0.5% ropivacaine reduced the prevalence of CPSP at three postoperative months from 46/89 (51.7%) to 22/90 (25.6%), relative risk (95% confidence interval): 0.47 (0.31–0.72), P < 0.001. The prevalence of CPSP was reduced at six months from 37/89 (41.6%) to 17/90 (18.9%), relative risk (95% confidence interval): 0.72 (0.58–0.88), P = 0.001. Moreover, SAPB decreased the area under the curve of the numeric rating scale pain scores over 24 h, shortened the length of post-anesthesia care unit stay, reduced postoperative 24-h morphine consumption and the occurrence of postoperative nausea and vomiting, and improved quality of recovery and patient satisfaction, with P < 0.05 for all. No SAPB-related complications occurred.ConclusionsPreoperative SAPB with ropivacaine improved acute postoperative analgesia and quality of recovery and decreased the prevalence of CPSP at three and six months after modified radical mastectomy.     

Efficacy of systemic lidocaine on postoperative quality of recovery and analgesia after video-assisted thoracic surgery: A randomized controlled trial

Study objectiveIntraoperative systemic lidocaine has become widely accepted as an adjunct to general anesthesia, associated with opioid-sparing and enhanced recovery. We hypothesized that perioperative systemic lidocaine improves postoperative pain and enhances the quality of recovery (QoR) in patients following video-assisted thoracic surgery (VATS).DesignProspective, single-center, double-blind, randomized placebo-controlled clinical trial.SettingSingle institution, tertiary university hospital.PatientsAdult patients aged 18 to 65 undergoing VATS were eligible for participation.InterventionsPatients enrolled in this study were randomized to receive either system lidocaine (a bolus of 1.5 mg kg⁻¹, followed by an infusion of 2 mg kg⁻¹ h⁻¹ until the end of the surgical procedure) or identical volumes and rates of 0.9% saline.MeasurementsThe primary outcome was a global QoR-15 score 24 h after surgery. Secondary outcomes included postoperative pain score, cumulative opioid consumption, emergence time, length of PACU stay, adverse events, and patient satisfaction.Main resultsThere was no difference in the global QoR-15 scores at 24 h postoperatively between the lidocaine and saline groups (median 117, IQR 113.5–124, vs. median 116, IQR 111–120, P = 0.067), with a median difference of 3 (95% CI 0 to 6, P = 0.507). Similarly, postoperative pain scores, postoperative cumulative opioid consumption, PACU length of stay, the occurrence of PONV, and patient satisfaction were comparable between the two groups (all P > 0.05).ConclusionsOur current findings do not support using perioperative systemic lidocaine as a potential strategy to improve postoperative pain and enhance QoR in patients undergoing VATS.Trial registrationChinese Clinical Trial Registry (identifier: ChiCTR1900027515).