Efficacy of Two Unique Combinations of Nerve Blocks on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Study

BackgroundThis study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA).MethodsPatients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications.ResultsCompared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates.ConclusionAdding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.     

Quantifying Patient Engagement in Total Joint Arthroplasty Using Digital Application-Based Technology

BackgroundDigital patient engagement has been suggested as a mean to increase patient activation and patient satisfaction after total joint arthroplasty. The purpose of this study was to assess patient engagement with application-based educational tools and to explore what content was most useful to patients in the perioperative period surrounding total hip arthroplasty (THA) and total knee arthroplasty (TKA), respectively.MethodsPatients undergoing THA and TKA between October 2017 and January 2020 were enrolled to use an application-based digital technology. The App provides comprehensive patient education using a series of modules delivered at set intervals preoperatively and postoperatively. Patient engagement was defined as patients viewing at least one time the modules that were sent, or marking them as completed. Patient satisfaction was assessed using an in-application survey.ResultsComplete data were available on 207 patients of which 95 (46%) underwent THA and 112 (54%) underwent TKA. The average age was 60 years. 54% with patients invited to the program completed registration. An average compliance rate of 48% (41 modules engaged out of 83) was observed. Of all modules completed, the top three most popular categories included physical therapy/exercise videos, health literacy, and anxiety/stress/pain management. The least viewed category was nutrition planning and education.ConclusionWhen presented educational material related to THA and TKA, patients had a high rate of compliance. Digital technology platforms provide a scalable, meaningful approach to engaging patients throughout the continuum of joint replacement care and may serve as a cost-effective adjunct to traditional methods.     

2-Octyl Cyanoacrylate Topical Adhesive as an Alternative to Subcuticular Suture for Skin Closure After Total Knee Arthroplasty: A Randomized Controlled Trial in the Same Patient

BackgroundThe 2-octyl cyanoacrylate topical adhesive with flexible self-adhesive polyester mesh (Dermabond Prineo) is becoming widely used in many surgical fields. However, no prior studies have tested the efficacy and safety of this topical adhesive compared with subcuticular suture in the same patient. The purpose of this study was to compare the efficacy and safety between Dermabond Prineo and subcuticular suture for skin closure in patients undergoing same-day bilateral total knee arthroplasties (TKAs).Materials and MethodsA prospective, double-blind randomized controlled trial was performed in 51 patients scheduled to undergo same-day bilateral TKAs. One knee was randomly assigned to the Dermabond Prineo and the other knee was allocated to the subcuticular suture. As primary outcomes, Vancouver scar scale was evaluated at 6 months and Patient and Observer Scar Assessment Scale was evaluated at 2 weeks, 6 weeks, 3 months, and 6 months. Secondary outcomes included cosmesis efficacy (Hollander wound evaluation scale [HWES] and cosmesis visual analog scale [VAS]), time and pain efficiency (skin suture time, stitch out time, and stitch out pain VAS), and safety (wound complications during the 6-month follow-up period). The primary and secondary outcome measures were compared between groups.ResultsThere were no significant differences in Vancouver scar scale and Patient and Observer Scar Assessment Scale at 6 months. Although there were no significant differences in HWES at 2 weeks, the Dermabond Prineo group showed better step-off border item of HWES. There was also no difference in cosmesis VAS at 6 months. The Dermabond Prineo group showed superior results in terms of time (suture time: Dermabond Prineo = 191 second (sec) ± 60.1 sec, subcuticular suture = 356.8 sec ± 92.3 sec; stitch out time: Dermabond Prineo = 4 sec ± 1.3 sec, subcuticular suture = 26.6 sec ± 4.2 sec, all P < .001) without significant differences in pain scale (P = .823) or wound complications (all P > .05).ConclusionComparing cosmetic efficacy, time efficiency, and safety, Dermabond Prineo provided quicker wound closure, shorter stitch out time, and better wound margin coaptation in the early postoperative period but similar cosmetic efficacy compared with subcuticular suture. Based on our study, Dermabond Prineo is a useful alternative to subcuticular suture in patients undergoing TKA.Level of EvidenceTherapeutic level 1.     

Highly Crosslinked Polyethylene Can Reduce Wear Rate in THA for High-Demand Patients: A Matched-Paired Controlled Study

BackgroundThe average age of patients benefiting from total hip arthroplasty (THA) has been declining. In addition to pain relief, patients seek to return to physical activity. However, the latter may increase polyethylene wear and therefore the potential risk of early aseptic loosening. The introduction of highly crosslinked polyethylene (HXLPE) has reduced wear rates in the general patient population. The objective of this study was to evaluate the influence of impact sports in patients operated with THA using ceramic-on-conventional polyethylene (cPE) versus ceramic-on-HXLPE, in terms of wear and function, with a minimum of five year follow-up.MethodsSixty-eight patients practicing an impact sport (University of California Los Angeles score ≥8) who underwent a primary THA were included: 34 with a ceramic-on-cPE versus 34 with a ceramic-on-HXLPE using the same cementless acetabular and femoral component. Patients were matched-paired by age, sex, BMI, and University of California Los Angeles score. The wear analysis was performed using the IMAGIKA software. The Harris hip score and hip and osteoarthritis outcome score were collected.ResultsThe linear wear rate was statistically higher (P < .0001) in the cPE group (0.13503 ± 0.0630 mm/year) than in the HXLPE group (0.03059 ± 0.0084 mm/year). Postoperatively, the increase in Harris hip score was calculated at 37.64 for the entire cohort and was comparable in both groups (P = .3674). The hip and osteoarthritis outcome score for pain (P = .0009), daily life activities (P = .0016), and quality of life (P = .0179) were significantly higher in the HXLPE group, with, between groups, a difference inferior to the reported minimal clinical important difference. Three patients exhibited signs of periprosthetic osteolysis in the cPE group, one on the femoral side and two on the acetabular side. None were observed in the HXLPE group. No revision for aseptic loosening was reported in both cohorts.ConclusionPatients partaking in impact sports and receiving a ceramic-on-HXLPE THA demonstrated lower wear and osteolysis rates than those having a ceramic-on-cPE THA, with similar functional results.     

Heterotopic Ossification Negatively Influences Range of Motion After Revision Total Knee Arthroplasty

BackgroundThe incidence of heterotopic ossification (HO) after total knee arthroplasty (TKA) varies and is of unclear clinical significance. This study aimed to identify the incidence of HO in patients undergoing revision TKA for either stiffness or aseptic loosening/instability and determine if the presence of HO is associated with inferior absolute range of motion (ROM) and ROM gains.MethodsEighty-seven patients were prospectively enrolled and separated into 2 cohorts to evaluate ROM after revision TKA (2017-2019). Group 1 (N = 40) patients were revised for stiffness, while group 2 (N = 47) patients were revised for either aseptic loosening or instability. Goniometer-measured ROM values were obtained preoperatively and at 6 weeks, 6 months, and 1 year postoperatively. Statistical analysis included a Fisher’s exact test to assess for an association between preoperative HO and final ROM at 1 year after revision TKA.ResultsHO was identified on preoperative radiographs in 17 patients (20%). There was a significantly higher rate of preoperative HO in patients revised for stiffness compared to patients revised for instability or loosening (30% vs 11%; P = .03). Five cases of HO qualitatively identified as most clinically severe were associated with lower ROM at each time point compared to the remainder of HO cases in this study cohort (P < .02).ConclusionThe presence of HO is greater in patients undergoing revision TKA for stiffness. Additionally, HO severity appears to have a major effect on preoperative and postoperative ROM trajectory. This information should help guide patient expectations and highlight the need for a comprehensive, standardized classification system for HO.     

Total Femur Antibiotic Spacers: Effective Salvage for Complex Periprosthetic Joint Infections

BackgroundA simultaneous periprosthetic joint infection (PJI) of an ipsilateral hip and knee arthroplasty is a challenging complication of lower extremity reconstructive surgery. We evaluated the use of total femur antibiotic-impregnated polymethylmethacrylate (PMMA) bone cement spacers in the staged treatment of such limb-threatening PJIs.MethodsThirteen patients were treated with a total femur antibiotic spacer. The mean age at the time of spacer placement was 65 years. Nine patients had polymicrobial PJIs. All spacers incorporated vancomycin (3.0 g/40 g PMMA) and gentamicin (3.6 g/40 g PMMA), while 8 also included amphotericin (150 mg/40 g PMMA). Eleven spacers were biarticular. Twelve spacers were implanted through one longitudinal incision, while 8 of 12 reimplantations occurred through 2 smaller, separate hip and knee incisions. Mean follow-up after reimplantation was 3 years.ResultsTwelve (92%) patients underwent reimplantation of a total femur prosthesis at a mean of 26 weeks. One patient died of medical complications 41 days after spacer placement. At latest follow-up, 3 patients had experienced PJI recurrence managed with irrigation and debridement. One required acetabular component revision for instability. All 12 reimplanted patients retained the total femur prosthesis with no amputations. Eleven (91%) were ambulatory, and 7 (58%) remained on suppressive antibiotics.ConclusionTotal femur antibiotic spacers are a viable, but technically demanding, limb-salvage option for complex PJIs involving the ipsilateral hip and knee. In the largest series to date, there were no amputations and 75% of reimplanted patients remained infection-free. Radical debridement, antimicrobial diversity, prolonged spacer retention, and limiting recurrent soft tissue violation are potential tenets of success.Level of EvidenceIV.     

Patients Receiving a Primary Unicompartmental Knee Replacement Have a Higher Risk of Revision but a Lower Risk of Mortality Than Predicted Had They Received a Total Knee Replacement: Data From the National Joint Registry for England,Wales, Northern Ireland,and the Isle of Man

BackgroundTo determine unicompartmental (UKR) and total knee replacement (TKR) revision rates, compare UKR revision rates with what they would have been had they received TKR instead, and assess subsequent re-revision and 90-day mortality rates.MethodsUsing National Joint Registry data, we estimated UKR and TKR revision and mortality rates. Flexible parametric survival modeling (FPM) was used to model failure in TKR and make estimates for UKR. Kaplan-Meier estimates were used to compare cumulative re-revision for revised UKRs and TKRs.ResultsTen-year UKR revision rates were 2.5 times higher than expected from TKR, equivalent to 70 excess revisions/1000 cases within 10 years (5861 excess revisions in this cohort). Revision rates were 2.5 times higher for the highest quartile volume UKR surgeons compared to the same quartile for TKR and 3.9 times higher for the lowest quartiles respectively. Re-revision rates of revised TKRs (10 years = 17.5%, 95% confidence interval [CI] 16.4-18.7) were similar to revised UKRs (15.2%, 95% CI 13.4-17.1) and higher than revision rates following primary TKR (3.3%, 95% CI 3.1-3.5). Ninety-day mortality rates were lower after UKR compared with TKR (0.08% vs 0.33%) and lower than predicted had UKR patients received a TKR (0.18%), equivalent to 1 fewer death per 1000 cases.ConclusionUKR revision rates were substantially higher than TKR even when demographics and caseload differences were accounted for; however, fewer deaths occur after UKR. This should be considered when forming treatment guidelines and commissioning services. Re-revision rates were similar between revised UKRs and TKRs, but considerably higher than for primary TKR, therefore UKR cannot be considered an intermediate procedure.     

Impact of Perioperative Pain Control on Knee Range of Motion and Development of Arthrofibrosis Following Primary Total Knee Arthroplasty

BackgroundInadequate pain control following total knee arthroplasty (TKA) has been postulated to negatively impact knee range of motion (ROM). We sought to determine the association between perioperative pain levels and knee ROM at 3-month follow-up or need for manipulation under anesthesia (MUA).MethodsWe retrospectively reviewed 2243 primary TKAs performed from 2002 to 2019 at a single academic center using an institutional total joint registry. Mean age was 68, mean body mass index was 32.8, and 59% were female. Knee ROM was measured preoperatively and 3 months postoperatively. Change in knee ROM, rates of soft tissue contracture, and MUA were assessed in relation to in-hospital 10-point pain visual analog scale (VAS) measurements.ResultsOverall, 44% had improved ROM at 3-month follow-up, 29% had no change in ROM, and 27% had worsened ROM. There was no significant difference in mean VAS scores of patients with improved, unchanged, or worsened ROM postoperatively (3.0 vs 2.8 vs 3.0; P = .068). There was no significant difference in mean VAS scores of patients who developed a soft tissue contracture or required MUA vs those who did not develop these complications (2.7 vs 2.9; P = .24). Similarly, no significant relationship with these outcomes was identified when maximum and discharge VAS scores were analyzed.ConclusionComparable ROM and rates of MUA based on in-hospital pain levels were observed in this large series of primary TKA patients. While significant early pain may limit participation in ROM exercises initially, this does not appear to have a marked impact on ROM-related complications for most patients.Level of EvidenceIII, Therapeutic.     

Revision Total Knee Arthroplasty in Young Patients: Higher Early Reoperation and Rerevision

BackgroundRevision total knee arthroplasty (rTKA) rates are increasing in younger patients. Few studies have assessed outcomes of initial aseptic rTKA performed for younger patients compared with traditional-aged patients.MethodsA detailed medical record review was performed to identify patient demographics, medical comorbidities, surgical rTKA indications, timing from index TKA to rTKA, subsequent reoperation rates, component rerevision rates, and salvage procedures for 147 young patients (158 knees) aged 55 years and younger and for a traditional older cohort of 276 patients (300 knees) between 60 and 75 years. Univariate analysis was performed to assess differences in these primary variables, and a log-rank test was used to estimate 5-year implant survival based on either reoperation or component revision and salvage procedures.ResultsYounger TKA patients were more likely to undergo initial aseptic rTKA within 2 years of their primary TKA (52.5% vs 29.0%, P < .001) and were more likely to undergo early reoperation (17.7% vs 9.7%, P = .02) or component rerevision (11.4% vs 6.0%, P < .05) after rTKA. Infection and extensor mechanism complications were more commonly noted in younger patients. Estimated 5-year survival was also lower for both reoperation (59.4% vs 65.7%, P = .02) and component rerevision or salvage (65.8% vs 80.1%, P = .02).ConclusionEarly reoperation and component re-rTKA were performed nearly twice as often in younger rTKA than traditional-aged TKA patients. Care should be given to reduce perioperative infection and extensor mechanism failures after rTKA in younger patients.     

Risk Factors and Effect of Acute Kidney Injury on Outcomes Following Total Hip and Knee Arthroplasty

BackgroundDevelopment of acute kidney injury (AKI) following primary total joint arthroplasty (TJA) is a potentially avoidable complication associated with negative outcomes including discharge to facilities and mortality. Few studies have identified modifiable risk factors or strategies that the surgeon may use to reduce this risk.MethodsWe identified all patients undergoing primary TJA at a single hospital from 2005 to 2017, and collected patient demographics, comorbidities, short-term outcomes, as well as perioperative laboratory results. We defined AKI as an increase in creatinine levels by 50% or 0.3 points. We compared demographics, comorbidities, and outcomes between patients who developed AKI and those who did not. Multivariate regressions identified the independent effect of AKI on outcomes. A stochastic gradient boosting model was constructed to predict AKI.ResultsIn total, 814 (3.9%) of 20,800 patients developed AKI. AKI independently increased length of stay by 0.26 days (95% confidence interval [CI] 0.14-0.38, P < .001), in-hospital complication risk (odds ratio = 1.73, 95% CI 1.45-2.07, P < .001), and discharge to facility risk (odds ratio = 1.26, 95% CI 1.05-1.53, P = .012). Forty-one predictive variables were included in the predictive model, with important potentially modifiable variables including body mass index, perioperative hemoglobin levels, surgery duration, and operative fluids administered. The final predictive model demonstrated excellent performance with a c-statistic of 0.967.ConclusionOur results confirm that AKI has adverse effects on outcome metrics including length of stay, discharge, and complications. Although many risk factors are nonmodifiable, maintaining adequate renal perfusion through optimizing preoperative hemoglobin, sufficient fluid resuscitation, and reducing blood loss, such as through the use of tranexamic acid, may aid in mitigating this risk.