Long-Term Outcome Following Revision Total Knee Arthroplasty is Associated With Indication for Revision

BackgroundThere is limited information about long-term clinical outcomes following revision total knee arthroplasty (TKA) in relation to the indication for revision. Previously, a clear relation between indication for revision and clinical outcome was shown after 2 years. Present study evaluated (1) whether the reported association at 2 year remains present at 7.5 years, and (2) how clinical outcome at 7.5 years developed compared to baseline and 2-year follow-up, and (3) whether patients had additional adverse events.MethodsA cohort of 129 patients with a total system revision TKA was selected. Range of motion, Visual Analog Scale for pain and satisfaction, and clinical and functional Knee Society Score were obtained preoperatively, at 3 months, 1, 2, and 7.5 years. Reasons for revision were septic loosening, aseptic loosening, malposition, instability, and severe stiffness.ResultsPatients revised for severe stiffness had significantly worse outcomes. No difference was found between the other indications. The clinical outcome after revision TKA at 7.5 years remained stable for septic and aseptic loosening, malposition, and instability but deteriorated slightly for the severe stiffness group. Visual Analog Scale satisfaction remained constant for all indications. There were 11 additional complications between 2- and 7.5-year follow-up, 9 of which necessitated reoperation.ConclusionAll indications except severe stiffness had a similar clinical outcome which was maintained up to 7.5-year follow-up. The severe stiffness group had worse outcomes and deteriorated slightly at longer follow-up. Outcome at 3 months seems predictive for long-term outcome. Additional complications did not differ significantly for the different reasons for revision.Level of EvidenceLevel III, prognostic study.     

全膝关节置换术后股神经阻滞自控镇痛的随机对照研究

目的比较患者自控与恒速输注2种给药方案对全膝关节置换术后患者股神经阻滞镇痛的效果。方法 2010年3月～11月选择60例单侧全膝关节置换术,椎管内麻醉前在超声及神经刺激器引导下置入连续股神经阻滞导管,将阻滞效果完全的患者按随机数字表随机分为2组：恒速输注组（CI组）和患者自控镇痛组（PCA组）。CI组经导管持续输注0.2%罗哌卡因5 ml/h,PCA组输注0.2%罗哌卡因背景量5 ml/h,单次注射5 ml/次,锁定时间60 min。记录2组患者静息痛及运动状态下疼痛评分、满意率以及不良反应发生情况。结果 3例在首次给药后30 min内没有达到完全阻滞而被排除。术后1～3 d静息及主动锻炼时疼痛评分2组无显著性差异（P〉0.05）。术后1～3 d被动锻炼时疼痛评分PCA组（4.7±1.3,4.5±1.0,4.5±1.0）显著低于CI组（6.5±1.6,6.1±1.6,5.9±1.6）（P〈0.05）。患者满意度PCA组显著高于CI组[8（6～10）vs.7（4～9）]（Z=16.957,P=0.031）。2组患者均无耳鸣、口周麻木、眩晕等局麻药中毒症状同,均无因下肢无力而跌倒,无导管脱出。结论与恒速输注相比,患者自控股神经阻滞能够提高术后康复运动时的镇痛效果。     

Opioid-Sparing Analgesia and Enhanced Recovery After Total Knee Arthroplasty Using Combined Triple Nerve Blocks With Local Infiltration Analgesia

Background

Peripheral nerve block and local infiltration analgesia (LIA) have an increasing role as part of multimodal analgesia for enhanced recovery after total knee arthroplasty (TKA). We hypothesized that the combination of obturator nerve block (ONB) and tibial nerve block (TNB) would reduce pain and opioid consumption more than ONB or TNB alone when combined with continuous adductor canal block and LIA.

Adductor Canal Block Combined With IPACK Block for Postoperative Analgesia and Function Recovery Following Total Knee Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Study

BackgroundThis study aimed to explore the analgesic effect among adductor canal block (ACB) combined with infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) block, ACB, and IPACK block following total knee arthroplasty (TKA).MethodsOne hundred twenty patients were randomly allocated into 3 groups including group A (ACB + IPACK block), group B (ACB), and group C (IPACK block). The primary outcome was postoperative pain score. The secondary outcome was opioid consumption. Other outcomes included functional evaluation and postoperative complications.ResultsGroup A showed the lowest pain scores within 8 hours at rest and with knee maximum flexion (P < .001). From 12 to 24 hours, group C showed the highest pain scores, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups 24 hours postoperatively. Group C showed the most opioid consumption within the first 24 hours and during the hospitalization, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups including function evaluation and postoperative complications.ConclusionACB + IPACK block can improve early analgesia when compared with ACB. However, the small statistical benefit to the addition of IPACK block to ACB may be unlikely to be clinically significant. Further studies may focus on patient selection and how to prolong the effect of IPACK block.     

股神经和硬膜外自控镇痛在全膝关节置换术后的效果比较

目的：比较股神经和硬膜外自控镇痛在膝关节置换术后的效果和副作用。方法：选择ASAⅠ～Ⅱ级行单侧膝关节置换术患者50例,随机分为股神经自控镇痛组（PCFNA,n=25）和硬膜外自控镇痛组（PCEA,n=25）。均在单侧蛛网膜下腔阻滞麻醉下施术,术后通过留置导管连接0.2%罗哌卡因、2μg/mL芬太尼止痛泵镇痛。结果：两组在术后各时点静息VAS和吗啡用量、副作用的发生率无统计学差异。PCFNA组持续被动功能训练时的VAS疼痛评分均明显低于PCEA组患者（P〈0.01）;PCFNA组术后24h患肢股四头肌的肌力略低,非手术侧肌力略高（P〈0.000）。结论：股神经自控镇痛在持续被动运动镇痛效果优于硬膜外自控镇痛,不影响非手术侧股四头肌肌力,有利于早期下床活动。     

Intra-articular Corticosteroid Injection Following Total Knee Arthroplasty: Is It Effective?

Background

Total knee arthroplasty (TKA) for the majority of patients with severe knee osteoarthritis provides relief of symptoms and improved function. However, there remains a subset of dissatisfied patients despite an unremarkable workup. A corticosteroid injection (CSI) is a commonly used nonsurgical treatment for painful knee osteoarthritis but its efficacy in a replaced knee remains unknown.

Use of Postoperative TENS and Continuous Passive Motion Following Total Knee Replacement

This randomized study analyzed the effectiveness of postoperative transcutaneous electrical nerve stimulation (TENS) used continuously for the first three postoperative days following total knee replacement (TKR) for 1) pain relief, 2) knee flexion arc, 3) narcotic dosage, and 4) hospital stay. Group 1 (N = 18) received sensory threshold TENS and group 2 (N = 18) received subthreshold TENS. Both groups also used continuous passive motion during their hospitalization as did patients from group 3 (control, N = 12) that did not receive TENS. Pain decrease from postoperative day 1-3 was 50% for group 1 patients and 38% for group 2 patients, as measured by the visual analog scale. Wilcoxon Rank Sum did not show a significant difference (p > 0.05) for pain relief or hospital stay for these two groups. Analysis of variance failed to show significant differences (p > 0.05) for knee flexion arc or narcotic dosage for the three groups. Although not statistically significant, an observed decrease in pain may be the only indication for postoperative TENS after TKR. J Orthop Sports Phys Ther 1990;11(12):599-604.     

Efficacy of Adding Acetaminophen to Preemptive Multimodal Analgesia in Total Knee Arthroplasty: A Double-blinded Randomized Study

Objective

Preemptive multimodal analgesia is a frequently utilized method for controlling pain after total knee arthroplasty (TKA). So far, no studies have specifically examined the efficacy of adding acetaminophen to preemptive multimodal analgesia in TKA. The current work aimed to assess the efficacy of adding acetaminophen to preemptive multimodal analgesia for clinical pain management after TKA.

Methods

This was a double-blinded randomized study including 80 cases randomized to the acetaminophen and control groups, respectively. The acetaminophen group was administered celecoxib at 400 mg, pregabalin at 150 mg, and acetaminophen at 300 mg 2 h before TKA. Control patients were administered celecoxib, pregabalin, and placebo. The primary outcome was postsurgical use of morphine hydrochloride for rescue analgesia. Secondary outcomes included the time to the initial rescue analgesia, postsurgical pain as determined by a visual analogue scale (VAS), functional recovery as reflected by the range of knee motion and ambulation distance, hospitalization duration, and complication rates. Continuous data with normal and skewed distributions were compared by the Student's t test and the Mann–Whitney U test, respectively. Categorical variables were compared by the Pearson's chi-squared test.

Results

The control and acetaminophen groups were comparable in postoperative 0–24 h morphine consumption (11.3 ± 6.5 mg vs 12.3 ± 7.7 mg, P = 0.445) and total morphine consumption (17.3 ± 10.1 mg vs 19.3 ± 9.4 mg, P = 0.242). Additionally, time to the initial rescue analgesia, postoperative VAS score at any time point, postoperative functional recovery of the knee, and hospitalization duration were similar in both groups. Both groups also had similar occurrence rates of postoperative complications.

Conclusions

In this study, adding acetaminophen to preoperative preemptive multimodal analgesia did not decrease postoperative morphine use or ameliorate pain relief. The efficacy of adding acetaminophen to preemptive multimodal analgesia in TKA need to be further explored in future studies.     

Efficacy of Intravenous Acetaminophen for Postoperative Analgesia in Primary Total Knee Arthroplasty

Background

The use of intravenous acetaminophen has seen recent enthusiasm as one component of a multimodal approach to pain management. However, there is a lack of literature examining the efficacy of intravenous acetaminophen for pain control in total joint arthroplasty. The purpose of this study was to evaluate the efficacy of intravenous acetaminophen following primary total knee arthroplasty.

Design Modifications of the Posterior-Stabilized Knee System May Reduce Anterior Knee Pain and Complications Following Total Knee Replacement

Background

In total knee arthroplasty (TKA), advances in posterior-stabilized (PS) knee implant designs address patellofemoral mechanics and cam–post engagement in an effort to reduce patellofemoral pain and improve knee kinematics. Such modifications may include improved femoral rollback, improved femoral dislocation resistance, minimized wear, and improved longevity.

Questions/Purposes

In this study, we compared a newer PS knee design that incorporates a left and right specific femoral component and smoother trochlear groove to improve patellofemoral mechanics with an older PS design in order to assess patellofemoral pain, manipulation rates, and revision rates.

Methods

Using an institutional database, we retrospectively identified TKAs performed by the same surgeon using the Logic^® PS knee system and the older Optetrak PS knee system (Exactech Inc., Gainesville, FL, USA), with a minimum 2-year follow-up. Clinical outcomes for each cohort were measured using the Knee Society Clinical Rating System, University of California Los Angeles Activity Scale, pain visual analog scale (VAS), Veterans Rand 12-Item Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index. In addition, rates of anterior knee pain, manipulation, and revision were compared between the two knee systems, and a Kaplan–Meier survivorship curve defining failure as need for revision was calculated to allow comparison between the cohorts.

Results

From 2000 to 2018, there were 1482 TKAs performed using the Logic PS (not counting 12 patients who had died) and 445 in the Optetrak PS group (not counting 20 patients who had died). In the Logic PS and Optetrak PS groups, respectively, the average age at operation was 66.7 years and 68.6 years and the average body mass index was 30.8 and 31.2. Pain VAS scores were significantly lower in the Logic PS group than in the Optetrak group (1.72 vs. 2.75 out of 10, respectively). There was also a significant difference in the percentages of patients reporting anterior knee pain in the Logic group, as compared with the Optetrak group (5.6% vs. 11.8%, respectively). In addition, manipulation rates differed significantly between the Logic and Optetrak groups (0.34% vs. 10.70%, respectively). The revision rates were 1.15% for the Logic group and 2.0% for the Optetrak group. However, there was a significant difference in rates of revision performed because of osteolysis, favoring the Logic group (0.07% vs. 0.6%). The Kaplan–Meier survivorship curve shows a significant difference in time until revision between the Logic and Optetrak groups.

Conclusion

Design modifications to improve patellofemoral mechanics demonstrated significant improvements in overall pain and patellofemoral pain and reduced manipulation rates post-operatively.

     

Rapid Discharge to Home After Total Knee Arthroplasty Is Safe in Eligible Medicare Patients

Background

This study was aimed at assessing the risk of readmission for Medicare patients discharged home within a day of total knee arthroplasty (TKA) compared to those discharged on day 2 or beyond in a community medical center.

Predicting Acute Recovery of Physical Function Following Total Knee Joint Arthroplasty

The objective was to explore predictors of physical function during acute in-patient rehabilitation within a few days after TKA. Physical function status of participants (n = 72) three days after total knee arthroplasty (TKA) was measured using the Timed Up and Go Test (TUG) and the function subscale of the Western Ontario McMaster Universities Index of Osteoarthritis (WOMAC-function). Potential predictors of physical function were measured day one post-TKA. Their relationship with physical function was examined using backward elimination, multiple regression analyses. Older age and increased comorbidity were associated (R² = 0.20) with worse TUG times. Increased pain severity was associated (R² = 0.08) with worse WOMAC-function scores. Age, comorbidity, and pain severity should be considered when predicting which patients will struggle with acute recovery post-TKA.     

Risk of Periprosthetic Joint Infection After Intra-Articular Corticosteroid Injection Following Unicompartmental Knee Arthroplasty

BackgroundPerioperative intra-articular joint injection is a known risk factor for developing prosthetic joint infection (PJI) in the immediate preoperative and postoperative periods for total knee arthroplasty, but is less defined in unicompartmental knee arthroplasty (UKA). The goal of this study was to elucidate the risk of developing PJI after intra-articular corticosteroid injection (IACI) into a post UKA knee.MethodsA retrospective review of a nationwide administrative claims database was performed from January 2015 to October 2020. Patients who underwent UKA and had an ipsilateral IACI were identified and matched 2:1 to a control group of primary UKA patients who did not receive IACI. Multivariate logistic analyses were conducted to assess differences in PJI rates at 6 months, 1 year, and 2 years.ResultsA total of 47,903 cases were identified, of which 2,656 (5.5%) cases received IACI. The mean time from UKA to IACI was 355 days. The incidence of PJI in the IACI group was 2.7%, compared to 1.3% in the control group. The rate of PJI after IACI was significantly higher than the rate in the control group at 6 months, 1 year, and 2 years (all P < .05). The majority of PJI occurred within the first 6 months following IACI (75%).ConclusionIn this study, IACI in a UKA doubled the risk of PJI compared to patients who did not receive an injection. Surgeons should be aware of this increased risk to aid in their decision-making about injecting into a UKA.Level of EvidenceIII, retrospective comparative study.     

Intra-articular Injections of Hyaluronic Acid and Other Drugs in the Knee Joint

Background:

Degenerative osteoarthritis of the knee (OA) affects 35% of persons older than 65 years. If pain persists after non-invasive treatment, some intra-articular drugs can be tried before surgical treatment.

Questions/Purposes:

The purpose of this article is to review the literature after 2006 with the aim of answering two questions: (1) Are intra-articular injections of corticosteroids (CS), hyaluronic acid (HA) and platelet-rich plasma (PRP) effective in painful knee OA? and (2) Which of these drugs is more effective?

Methods:

The search engines were MedLine and the Cochrane Library. The keywords used were: knee, osteoarthritis, and intra-articular injections. Eight hundred and forty-four articles were found but only 142 had been published after 2006. Of those, only 14 were selected and reviewed because they were strictly focused on the topic and the questions of this article.

Results:

The clinical efficacy of intra-articular injections of HA and CS in patients with knee OA has been demonstrated. Pain reduction after three to five weekly injections of HA lasts between 5 to13 weeks (sometimes up to 1 year). Pain reduction is less durable after CS injections (2 to 3 weeks). Recent reports indicate that PRP could have a better performance than HA in younger patients.

Conclusions:

Three to five weekly intra-articular injections of HA are recommendable in patients with knee OA before surgical treatment. CS injections have a very short effect. The efficacy and duration of PRP injections require further studies.     

The Risk of Acute Infection Following Intra-articular Corticosteroid Injection Into a Pre-existing Total Knee Arthroplasty

Background

No previous studies have investigated the risk of infection following intra-articular corticosteroid injection (IACI) into a pre-existing total knee arthroplasty (TKA). The aim of this study is to determine the risk of acute infection following IACI into a pre-existing TKA.

Comparing the Analgesia Effects of Single-injection and Continuous Femoral Nerve Blocks with Patient Controlled Analgesia after Total Knee Arthroplasty

We compared the analgesic effects of single-injection or continuous femoral nerve block (FNB) with intravenous patient controlled analgesia (PCA) opioids. Two hundred patients undergoing knee arthroplasty were randomized to one of the three regimens. Significant knee pain on movement at postoperative 24 h was reduced with single-injection (OR 0.30; 95% CI 0.12 to 0.74; P = 0.009) or continuous (OR 0.21; 95% CI 0.08 to 0.51; P = 0.001) FNB, compared with PCA. Allocation to FNBs also resulted in significantly less opioid consumption, fewer episodes of nausea and vomiting, and achieved knee flexion 90° earlier than allocation to PCA. Compared to single-injection FNB, patients with continuous FNB had lower pain scores on movement at 24 h (mean difference − 0.57; 95% CI − 1.14 to − 0.01; P = 0.045), consumed less opioid, and had fewer incidences of nausea and vomiting. The analgesic efficacy of single-injection and continuous FNBs was superior to PCA in the immediate postoperative period; with continuous FNB providing better analgesia than single-injection FNB.     

Comparing Efficacy of Three Methods of Tranexamic Acid Administration in Reducing Hemoglobin Drop Following Total Knee Arthroplasty

The ideal method of providing tranexamic acid (TXA) for decreasing hemoglobin drop after TKA is still controversial. In this clinical trial, 200 patients were randomly allocated to four groups. In group 1, 500 mg TXA was administered intravenously. In group 2, the joint irrigated with 3 g of TXA in 100 cc of saline. In group 3, 1.5 g of TXA was injected through the drain. Group 4 did not take TXA. Albeit all methods had a statistical effect on hemoglobin drop, drainage and number of transfused units when compared to controls, but intravenous injection of TXA seems to be much more effective in terms of reducing hemoglobin drop and transfused units; and what's more TXA injection by drain is more effective regarding to reducing postoperative drainage.     

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.     

Patellar Eversion Does Not Adversely Affect Quadriceps Recovery Following Total Knee Arthroplasty

Although avoiding patellar eversion during a total knee arthroplasty (TKA) has theoretical benefit in quadriceps recovery, there has been paucity of supportive objective clinical results. We prospectively designed the study whether TKA without patellar eversion has better quadriceps recovery in an objective, dynamometer study. Seventy-two knees undergoing TKA with midvastus approach were randomized into two groups according to patellar eversion or not. Clinical data and objective quadriceps recovery using a dynamometer were investigated preoperatively and postoperative at 6 weeks, 3 months, 6 months and 1 year. There were no statistical differences between two groups throughout the follow-up periods in recovery of quadriceps force or power and clinical data. Choosing to evert patella during TKA using midvastus approach would not adversely affect postoperative quadriceps recovery.     

A Multimodal Clinical Pathway Can Reduce Length of Stay After Total Knee Arthroplasty

Clinical pathways reduce length of stay which is critical for hospitals to remain financially sound. We sought to determine if a multimodal pathway focusing on pre-op discharge planning and pre-emptive pain and nausea management lead to reduced length of stay, better pain management, and more rapid functional gains without an increase in post-op complications. A multimodal pathway incorporating pre-op discharge planning and pre-emptive pain and nausea management was initiated in August of 2007. Physical therapy began the day of surgery. Two hundred eleven patients treated over a 3-month period with the new pathway were compared to 192 patients treated in the last 3 months of an older pathway. Length of stay, VAS scores for pain, and the incidence of nausea were compared. Length of time to achieve functional milestones while in hospital and the incidence of complications out to 6 months were compared. Average length of stay was reduced by 0.26 days. VAS scores for pain were lower. Several functional milestones were achieved earlier and complications were not increased. Efforts to control nausea were not successful and severe nausea was experienced in 40% of patients in both groups. This enhanced pathway can lead to an important reduction in length of stay. Although this reduction seems small, it can significantly increase patient throughput and increase hospital capacity. Post-op nausea continues to be an impediment in patient care after TKR.