Postoperative Pain Management in Total Knee Arthroplasty

Identifying factors associated with persistent opioid use after total joint arthroplasty: a retrospective review

OBJECTIVE

To identify predictors of persistent opioid use in opioid-naïve individuals undergoing total joint arthroplasty.

DESIGN

Retrospective cohort study.

SETTING

Maine Health System.

SUBJECTS

Opioid-naïve patients who underwent at least one total joint arthroplasty (knee, hip, or shoulder) between 2015 and 2020.

METHODS

Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression was used to create a predictive model for persistent opioid use after surgery from a US Electronic Health Record dataset in the Observational Medical Outcomes Partnership Common Data Model format. 75% of the data was used to build the LASSO model using 10-fold cross-validation and 25% of the data was used to determine the optimal probability threshold for predicting the binary outcome.

RESULTS

Out of 6432 patients, 12.3% (792) were identified as having persistent opioid use across combined total joint arthroplasties defined as at least one opioid prescription between 90 days and 1 year after surgery. Patients with persistent opioid use were more likely to be current smokers (OR 1.65), use antidepressants (OR 1.76), or have a diagnosis of post-traumatic stress disorder (OR 2.07) or a substance-related disorder (OR 1.69). Other factors associated with persistent opioid use included back pain (OR 1.43), dementia (OR 1.65), and body mass index over 40 (OR 2.50). The probability of persistent opioid use was not associated with age, sex, or ethnicity.

CONCLUSIONS

This predictive model for persistent opioid use after total joint arthroplasty shows promise as an evidence-based, validated, and standardized tool for identifying high-risk patients before surgery in order to target strategies and interventions to reduce the reliance on opioids for postoperative pain control.

Adductor Canal Block Combined With IPACK Block for Postoperative Analgesia After Total Knee Arthroplasty: A Retrospective Cohort Study

Background

There is no consensus on whether adductor canal block (ACB) combined with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) block can further increase analgesia and reduce opioid consumption after total knee arthroplasty (TKA) compared with ACB and periarticular infiltration analgesia (PIA).

Purpose

This study aimed to evaluate the effectiveness of combining ACB and PACK block on analgesia and functional recovery following TKA.

Methods

A retrospective cohort study was conducted involving 386 patients who underwent primary unilateral TKA at our institution from January 2020 to October 2022. Patients were divided into 3 groups and treated with PIA, ACB, or ACB combined with IPACK block, respectively. Primary outcomes were postoperative morphine consumption and visual analogue scale (VAS) pain scores. Secondary outcomes included functional recovery, evaluated by knee range of motion, quadriceps strength, daily mobilization distance, and postoperative length of stay. Other outcomes included incidence of complications.

Results

Patients in the ACB + IPACK group had significantly less morphine consumption on postoperative day 1 and during hospitalization than patients in the PIA and ACB groups. Furthermore, the ACB + IPACK group had significantly lower VAS scores at rest and during motion at 6, 12, and 24 hours postoperatively (but not at other time points), better knee range of motion on postoperative days 1 and 2 (but not day 3), and a greater daily mobilization distance on postoperative day 1 (but not days 2 and 3). The ACB + IPACK group had significantly lower incidences of postoperative nausea and vomiting than the PIA and ACB groups.

Conclusion

This retrospective cohort study suggests that a combination of ACB and IPACK block may have a greater effect than PIA or ACB alone on analgesia following TKA, while providing better functional recovery. Further study is warranted.

The frequency and impact of drug-related problems with postoperative medication reported by orthopaedic patients after discharge

Following orthopaedic surgery, medication is vital for recovery and preventing complications, however drug-related problems (DRPs) can hinder medication use. The prevalence, types, and impact of DRPs on patients' activities of daily living (ADL) and the medication involved are unknown. Insight is needed for targeted interventions.

AIM

Our study had four aims to assess 1) the prevalence and types of DRPs with postoperative medication in orthopeadic patients 6 weeks after discharge; 2) the perceived impact of the reported DRPs on patients' ADL; 3) the postoperative medication most frequently causing DRPs; and 4) the association between DRP numbers and patient- and disease-related characteristics.

METHODS

A cross-sectional study at a tertiary centre surveyed adult orthopaedic surgery patients 6 weeks post-surgery. Patients reported on demographics, DRPs and their ADL impact, health literacy, and medication beliefs. Clinical factors and medication use were extracted from medical records. Descriptive statistics and linear hierarchical regression analysis were conducted.

RESULTS

Out of 484 patients (mean (standard deviation (SD)) age 61.1 (±12.7) years, 61.6% female), 87.4% reported at least one DRP, with 39.7% indicating it impacted ADL. The most frequent DRPs involved inadequate drug use, including intentionally used less (49.8%) and stopped earlier (44.6%). The most impactful DRPs involved negative experiences, including insufficient effect (69.3%) and side effect (57.6%). Opioids caused the most DRPs, averaging 1.8 per patient. Impactful DRPs were associated with female sex, knee and spine surgery, medication concerns, and younger age.

CONCLUSION

Most patients experienced at least one DRP within 6 weeks post-discharge, with nearly half reporting an impact on ADL. Inadequate drug use and negative experiences, particularly with opioids, are the most urgent DRPs to address.

Association Between Anterior Knee Pain and Soft Tissue Gliding of the Anterior Knee Region After Total Knee Arthroplasty: A Cross-Sectional Study

OBJECTIVE(S)

To investigate the relationship between impaired gliding in the anterior knee region and anterior knee pain (AKP) in patients after total knee arthroplasty (TKA).

DESIGN

Cross-sectional study.

SETTING

Orthopedic hospital.

PARTICIPANTS

Patients aged >60 years who underwent TKA between June and September 2023 without abnormal components or postoperative infections.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Ultrasonography visualized the anterior knee soft tissues (subcutaneous tissue [SC], patellar tendon [PT], and infra-patellar fat pad [IFP]) during maximal voluntary isometric knee extension. Particle image velocimetry analyzed the SC, PT, and IFP flow velocities, organized into time-series data. Correlation coefficients of flow velocity between the SC and PT and between the PT and IFP were calculated to define the gliding coefficient. We measured AKP during walking and stair ascent and descent. Furthermore, we investigated the correlations between gliding coefficients and AKP and identified factors contributing to AKP using multiple regression analysis. The relationship between gliding coefficients and patient-reported outcomes was explored.

RESULTS

In total, 20 patients (mean age, 72.9years; postoperative period, 14.9weeks) were included. A significant positive correlation was observed between the SC-PT gliding coefficients and AKP. Multiple regression analysis identified the SC-PT gliding coefficient as a significant independent variable associated with AKP during stair descent. Additionally, the SC-PT gliding coefficients were found to have a significant negative correlation with patient-reported outcomes.

CONCLUSIONS

The impaired gliding between the SC and PT may contribute to AKP, specifically during stair descent. This finding suggests that soft tissue gliding plays a significant role in postoperative pain and activity limitations in patients who underwent TKA.

Predictors of Pain Management Outcomes Following Orthopaedic Surgery: A Systematic Review

BACKGROUND

Up to 80% of patients in the United States report dissatisfaction with pain management following orthopaedic surgery. Inadequate pain management is linked to negative outcomes, including increased costs, readmission rates, and chronic pain risk. Traditional pain management protocols often emphasise the biological components of pain, overlooking psychological and social. This systematic review addresses this gap by answering two key questions: (1) What factors are associated with increased risk of unsatisfactory pain management following orthopaedic surgery? (2) What are the key components of successful pain management protocols following orthopaedic surgery?

METHODS

PRISMA guidelines were followed with a search of relevant online databases. Studies were included if they were in English, provided patient feedback/satisfaction with pain management (quantitative studies) or provided satisfaction with pain management or healthcare team feedback (qualitative studies) or explored patient variables associated with satisfaction with pain management.

RESULTS

Of the 845 articles screened, 27 met the inclusion criteria. Synthesis suggested that while perceived severity and duration of pain are often assumed to be the primary drivers of patient satisfaction related to pain management, patients with a sense of control over their pain reported higher satisfaction, regardless of actual pain level. History of opioid misuse, patient expectations, and patient mental health were associated with dissatisfaction.

CONCLUSION

Pre-operative education and ongoing communication, particularly regarding patient risk-factors and multi-modal pain management strategies, appear to enhance patients' sense of control and satisfaction. Future research should explore whether individualised pre-operative education can improve satisfaction with post-surgical orthopaedic pain management.

Evolution and Hotspots in Bilateral Total Joint Arthroplasty Research: A Bibliometric Analysis

Background

Total joint arthroplasty (TJA) is a potent treatment for degenerative joint disorders. Bilateral total joint arthroplasty (BTJA) encompasses both bilateral total knee arthroplasty (BTKA) and bilateral total hip arthroplasty (BTHA). Both BTKA and BTHA can be performed as either a simultaneous procedure or a staged procedure. The goal of this study was to investigate trends in BTJA research, including pertinent authors, journals, countries, and papers. We also evaluated frequent keywords and topics to predict potential future study fields.

Methods

Articles published between 1982 and 2022 were retrieved from the Web of Science Core Collection of Clarivate Analytics. The search query included "hip" OR "knee" (Topic) AND "arthroplasty" OR "replacement" (Topic) AND "bilateral" OR "simultaneous" (Topic) AND 1992-2022 (Year published) AND Article (Document type). Metrics were imported for further analysis with Bibliometrix and VOSviewer.

Results

A total of 736 articles associated with BTJA were retrieved, originating from 44 countries with the United States being the biggest contributor. Top institutions were Cornell University and Ewha Womans University. Kim YH was the most productive and impactful author. The Journal of Arthroplasty had the highest impact and the greatest number of articles and citations. Williams Russo had the most cited article. Co-occurrence visualizations highlighted predominant topics in the literature.

Conclusions

Since 1982, there has been a growing interest in BTJA research. The United States institutions have been the primary providers in global scholarly production. This bibliometric analysis identified previous, present, and emergent tendencies in BTJA with the goal of forecasting new potential hotspots.

Is outpatient joint arthroplasty safe in a high volume academic centre? A retrospective monocentric study using an institutional pathway

PURPOSE

Hip and knee arthroplasties are daily procedures in orthopaedic departments. Recently, same-day discharge (SDD) became increasingly popular, but doubts remain about its safety and generalization. Our hypothesis is that outpatient arthroplasty, in a high volume centre and with an institutional protocol, is an effective and reliable practice.

METHODS

We realized a monocentric retrospective study of patients undergoing outpatient partial (UKA) or total (TKA) knee or hip arthroplasty (THA) in a high volume academic centre using a well-defined institutional pathway. Epidemiological data and complications occurring in the month following surgery were studied.

RESULTS

498 patients undergoing 501 arthroplasties (219 hips and 282 knees) were examined. The percentage of men and women was 60.28% and 39.72% respectively, mean age was 64.56 ± 9.59 years, mean BMI was 26.87 ± 4.2 and the most represented ASA score was 2. The success rate for same-day discharge was 97.21%. The most frequent causes of failure were urinary retention (28.6%), orthostatic hypotension (28.6%) and insufficiently controlled pain (14.3%). The readmission rate in the month following the operation was 0.8% and the rate of emergency department visits was 1.6%. Finally, the rate of early consultation visits was 7.98%. The comparison between success and failure subgroups in the outpatient setting of our cohort did not highlight statistically significant differences for studied parameters.

CONCLUSION

Outpatient arthroplasty, performed in a center used to managing such operations and with a well-established institutional pre- and post-operative protocol, is a safe practice.

Cryotherapy for Rehabilitation After Total Knee Arthroplasty: A Comprehensive Systematic Review and Meta-Analysis

OBJECTIVE

Despite being well-studied and widely utilized, the efficacy of cryotherapy after total knee arthroplasty (TKA) in enhancing early rehabilitation lacks consensus. The aim of this systematic review and meta-analysis was to investigate (1) whether cryotherapy is able to promote the rehabilitation of patients undergoing TKA and (2) whether continuous cold flow device has superior results than cold pack in cryotherapy.

METHODS

A comprehensive trial searching was performed in the PubMed, Embase, Cochrane Library, and Google Scholar electronic databases in May, 2024. Randomized controlled trials (RCTs) comparing cryotherapy with no cryotherapy or comparing continuous cold flow device with cold pack after TKA were included. The primary outcome was visual analogue scale (VAS) of pain, and secondary outcomes included opioid consumption, blood loss (hemoglobin decrease and drainage), range of motion (ROM), swelling, length of stay (LOS), and adverse event.

RESULTS

A total of 31 RCTs were included in this meta-analysis with 18 trials comparing cryotherapy with no cryotherapy and 13 trials comparing continuous cold flow device with cold pack. Pooled results showed cryotherapy group had significantly lower VAS scores than no cryotherapy group on postoperative day (POD) 1 (MD, -0.59 [95% CI, -1.14 to -0.04]; p = 0.04), POD 2 (MD, -0.84 [95% CI, -1.65 to -0.03]; p = 0.04), and POD 3 (MD, -0.86 [95% CI, -1.65 to -0.07]; p = 0.03). Cryotherapy group also showed reduced opioid consumption, reduced hemoglobin loss, decreased drainage, and improved ROM after TKA. Continuous cold flow device group had comparable VAS, opioid consumption, blood loss, ROM, knee swelling, and LOS with cold pack group.

CONCLUSION

Cryotherapy can effectively alleviate postoperative pain, reduce blood loss, improve ROM, and thus promote the postoperative rehabilitation for TKA patients, but the continuous cold flow device did not show better efficacy than cold packs. These findings support the routine use of cryotherapy for the rapid rehabilitation of TKA patients, and the traditional cold pack is still recommended.

Developing predictive models for residual back pain after percutaneous vertebral augmentation treatment for osteoporotic thoracolumbar compression fractures based on machine learning technique

BACKGROUND

Machine learning (ML) has been widely applied to predict the outcomes of numerous diseases. The current study aimed to develop a prognostic prediction model using machine learning algorithms and identify risk factors associated with residual back pain in patients with osteoporotic vertebrae compression fracture (OVCF) following percutaneous vertebroplasty (PVP).

METHODS

A total of 863 OVCF patients who underwent PVP surgery were enrolled and analyzed. One month following surgery, a Visual Analog Scale (VAS) score of ≥ 4 was deemed to signify residual low back pain following the operation and patients were grouped into a residual pain group and pain-free group. The optimal feature set for both machine learning and statistical models was adjusted based on a 2000-resample bootstrap-based internal validation via an exhaustive search. The area under the curve (AUC), classification accuracy, sensitivity, and specificity of each model were then calculated to evaluate the predictive performance of each model.

RESULTS

In our current study, two main findings were observed: (1) Compared with statistical models, ML models exhibited superior predictive performance, with SVM demonstrating the highest prediction accuracy; (2) several variables were identified as the most predictive factors by both the machine learning and statistical models, including bone cement volume, number of fractured vertebrae, facet joint violation, paraspinal muscle degeneration, and intravertebral vacuum cleft.

CONCLUSION

Overall, the study demonstrated that machine learning classifiers such as SVM can effectively predict residual back pain for patients with OVCF following PVP while identifying associated predictors in a multivariate manner.

Comprehensive Pain Management in Total Joint Arthroplasty: A Review of Contemporary Approaches

Background: Total hip and knee arthroplasties are among the most effective and widely performed procedures in modern medicine, providing substantial benefits to patients with end-stage osteoarthritis. These surgeries have transformed the treatment of degenerative joint disease, significantly enhancing functionality and quality of life for patients. Despite considerable advancements in surgical techniques and postoperative care, managing postoperative pain remains a major challenge, impacting both clinical recovery and patient satisfaction. The persistence of postoperative pain as a barrier to recovery underscores the need for improved pain management strategies. Methods: A comprehensive narrative review of the literature was conducted, focusing on the physiological mechanisms underlying surgical pain, the role of anesthesia techniques, and the development of multimodal pain management approaches used in total joint arthroplasty. This review emphasizes the components of modern multimodal strategies, which combine multiple pharmacologic and non-pharmacologic methods to address the various mechanisms of postoperative pain. Results: Current pain management strategies employ a dynamic, multimodal approach that covers the perioperative period. These strategies aim to optimize pain control while minimizing side effects. They incorporate a range of methods, including nerve blocks, non-opioid analgesics, opioids, and non-pharmacologic techniques such as physical therapy. However, evidence regarding the efficacy and optimal combinations of these interventions varies widely across studies. Conclusions: This variation has led to inconsistent pain management practices across institutions. To standardize and improve care, this paper presents the authors' institutional pain management model, offering a potential framework for broader application and adaptation in the field of joint arthroplasty.

Adductor canal block (ACB) plus infiltration of the posterior capsule of the knee (iPACK) block versus 4-in-1 block in an arthroscopic anterior cruciate ligament (ACL) repair: A randomised study

Background and Aims

Anterior cruciate ligament (ACL) repair is a common sports-related surgery requiring early rehabilitation. Injection between the popliteal artery and the capsule of the knee (iPACK) provides analgesia to the posterior knee and, when combined with adductor canal block (ACB), can provide complete analgesia for knee surgery. A 4-in-1 block, a single injection, has been studied for analgesia in TKR but not ACL repair. This study was done with the objective of comparing the postoperative analgesia of iPACK + ACB versus 4-in-1 block in ACL repair.

Methods

The study was conducted on 184 participants undergoing ACL repair in the age group of 18-70 years. Patients were randomly allocated to iPACK +ACB or 4-in-1 block. After the preoperative and intraoperative protocol, a guided nerve block was performed. The duration of motor blockade of spinal anaesthesia and pain scores were monitored using the visual analogue scale (VAS), and the time for first rescue analgesia was noted at 3, 6, 12, 24, and 36 hours. An independent sample t-test was used to find the association of all quantitative variables, and a Chi-square test was used to find the association of categorical variables with both groups of patients (P < 0.05).

Results

VAS scores were statistically similar between the two groups at 3, 6, 12, and 24 hours but were significantly less at 36 hours in group B (P < 0.001). The time to perform the regional block was lower in group B, a single injection technique (P < 0.001). None of the patients showed muscle weakness in the postoperative period and could cooperate reasonably with physiotherapy.

Conclusion

The 4-in-1 block provides non-inferior analgesia compared to the established iPACK plus ACB for arthroscopic ACL surgery.

Utility of Intranasal Tapentadol in Redefining Postoperative Pain Management in Total Knee Arthroplasty: A Prospective Observational Study

Introduction Effective strategies to minimize postoperative pain following total knee arthroplasty (TKA) are essential to improve functional outcomes. This study aimed to evaluate the effectiveness and safety of tapentadol nasal spray as a form of patient-controlled analgesia (PCA) for postoperative pain management after TKA. The intranasal route was chosen for the study as intranasal tapentadol has been shown to have superior pain reduction as compared to intravenous tapentadol. Intranasal instillation of tapentadol is rapid and more effective than the parenteral or oral route. Additional advantages of the intranasal route include enhanced comfort, convenience, and safety. Methods The present study was a single-center prospective observational study including 120 patients undergoing unilateral TKA who were administered tapentadol nasal spray post-surgery (22.5 mg of tapentadol per spray). Pain was objectively assessed using the visual analog scale (VAS) on postoperative days (POD) 1, 2, and 3, before and after spray administration. The pain severity was graded into mild (VAS 1-3), moderate (VAS 4-6), and severe (VAS 7-10) based on the VAS score. The time duration required for the pain severity to become mild from the pre-spray level post-administration of the nasal spray was recorded on all three PODs. The time required in hours for the pain severity to worsen from mild (VAS 1-3) to moderate (VAS 4-6) or severe (VAS 7-10) was also recorded on all three PODs. The statistical analysis plan for this study involved the analysis of VAS scores collected on PODs 1, 2, and 3. Categorical variables were expressed as percentages, while numerical variables were presented as means and standard deviations. The significance of differences between pre and post-treatment VAS scores was analyzed using Student's t-test. Differences between proportions were analyzed using the Chi-square or Fisher's exact test. The Kolmogorov-Smirnov test was used to test the normality of the quantitative data. The Analysis of Variance (ANOVA) test was applied to compare the means across the three PODs. A two-tailed significance level of 0.05 was set for all tests to determine statistical significance. Results The mean pre-spray VAS scores recorded on POD 1, 2, and 3 were 8.07, 7.64, and 7.40 respectively. The mean post-spray VAS scores recorded on POD 1, 2, and 3 were 4.63, 4.71, and 3.95 respectively. There was a statistically significant reduction in the VAS scores on each of the three days when measured before and after spray administration (p<0.001). The average time needed for the pain severity to become mild from the pre-spray level in minutes on POD 1, 2, and 3 was 14.07, 13.36, and 12.34 respectively. Thus, this metric significantly declined (p<0.001) from POD 1 to POD 3. The time taken in hours for the pain severity to worsen from mild to moderate or severe on POD 1, 2, and 3 was 6.57, 6.70, and 6.98 respectively indicating that there was a significant increase in the time till the pain severity worsened from POD 1 to POD 3 (p<0.001). There were no major drug-induced adverse reactions following the administration of intranasal tapentadol. Conclusion Intranasal tapentadol spray (22.5 mg per spray) is an acceptable modality of postoperative pain management in patients undergoing TKA. It has a long-lasting effect, rapid onset, minimal side effects, and can be self-administered by the patient.

Reducing Opioid Consumption and Length of Stay After Bariatric Surgery: A Nonpharmacologic ERAS Intervention Bundle

PURPOSE

To reduce opioid consumption and decrease length of stay (LOS) in bariatric surgical patients by implementing an evidence-based, nonpharmacologic enhanced recovery after surgery (ERAS) intervention bundle.

DESIGN

Evidence-based practice project.

METHODS

We developed and implemented a nonpharmacologic ERAS bundle from existing American Society of PeriAnesthesia Nurses Standards and bariatric and subspecialty surgical ERAS protocols to standardize the postoperative nursing care of bariatric patients. The bundle consisted of early ambulation, immediate initiation and prolonged use of oxygenation, prevention of nausea and vomiting, frequent use of incentive spirometry, and application of ice packs to surgical sites. The two project outcomes were opioid consumption and patient LOS. We used descriptive statistics to summarize opioid consumption and LOS among surgical bariatric patients at baseline and post intervention and independent samples t tests to determine the statistical significance of pre- or post-LOS changes.

FINDINGS

After implementing the ERAS bundle in 31 bariatric surgical patients, we found that the percentage of patients given an opioid substantially decreased by 13.8%, with both fentanyl and hydromorphone (Dilaudid) consumption meaningfully decreasing by 11.0% and 25.6%, respectively. The average LOS significantly decreased (P = .015) by 23 minutes per patient following the intervention, from 1 hour and 58 minutes to 1 hour and 35 minutes, representing a 19.5% reduction in total patient time in the PACU.

CONCLUSIONS

Use of a nonpharmacologic ERAS bundle and standardizing postoperative care decreased overall PACU bariatric surgical patient opioid consumption and significantly reduced PACU LOS. Optimizing pain management for bariatric patients in the PACU could lead to improved pain control and reduced reliance on opioids during their entire hospital stay, enhancing health care outcomes and improving patient safety. Perioperative leaders and educators can use our example to develop initiatives that decrease opioid use and LOS to improve care for the high-acuity bariatric patient population.

Nerve Blocks for Post-Surgical Pain Management: A Narrative Review of Current Research

Opioids remain the mainstay of post-surgical pain management; however, concerns regarding addiction and side effects necessitate the exploration of alternatives. This narrative review highlights the potential of nerve blocks as a safe and effective strategy for post-surgical pain control. This review explores the use of various nerve block techniques tailored to specific surgical procedures. These include nerve blocks for abdominal surgeries; fascial plane blocks for chest surgeries; nerve blocks for arm surgeries; and nerve blocks for lower limb surgery including; femoral, hip, and knee surgeries. By targeting specific nerves, these blocks can provide targeted pain relief without the negative side effects associated with opioids. Emerging evidence suggests that nerve blocks can be as effective as opioids in managing pain, while potentially offering additional benefits such as faster recovery, improved patient satisfaction, and reduced reliance on opioids. However, the effectiveness of nerve blocks varies depending on type of surgery, and in individual patients. Rebound pain, which temporary increase in pain after a block wears off, can occur. In addition, some techniques require specialized guidance for accurate placement. In conclusion, nerve blocks show great promise as effective alternatives for managing post-surgical pain. They can reduce the need for opioids and their side effects, leading to better patient outcomes and satisfaction. Future studies should assess the long-term impacts of specific nerve blocks on mortality rates, cost-effectiveness, and their incorporation into multimodal pain management approaches to further enhance post-surgical care.

Importance of hip capsular repair in total hip arthroplasty (THA) via the posterior lateral approach: a five year retrospective cohort study

PURPOSE

This study aims to assess the impact of repairing the hip joint capsule during posterior-lateral approach total hip arthroplasty (THA) on postoperative hip joint function and late dislocation incidence.

METHODS

A retrospective cohort study included 413 patients, divided into experimental (hip joint capsule repair, n = 204) and control (hip joint capsule excision, n = 209) groups. Patients were followed for five years, evaluating postoperative hip range of motion (ROM), dislocation rate, VAS and HHS scores, inflammatory and coagulation markers, hospitalization, blood loss, and body composition. Statistical analysis included the Student's t-test, Chi-square test, and logistic regression for dislocation risk factors.

RESULTS

Joint capsule repair improved postoperative hip flexion and extension within six months and at two years postoperatively, internal and external rotation within three months, and abduction and adduction throughout the entire follow-up period (P < 0.05). Capsular repair also reduced early and late dislocation rates (P < 0.05). Significant differences in HHS and VAS scores, inflammatory and coagulation indicators, hospitalization, blood loss, and body composition were noted (P < 0.05). Multivariate logistic regression indicated hip joint repair, rheumatoid arthritis, epilepsy, and sarcopenia as dislocation risk factors (P < 0.05).

CONCLUSIONS

Capsular repair during posterior-lateral THA improves postoperative hip function and mobility while reducing dislocation rates, blood loss, pain, inflammation, and economic burden. Patients with rheumatoid arthritis, epilepsy, or sarcopenia require individualized planning and enhanced postoperative care to minimize complications.

Comparative Analysis of Outcomes of Lateral Versus Medial Approach in the Total Knee Arthroplasty for Valgus Deformity: A Systematic Review and Meta-analysis

Background

Valgus knee deformity poses great challenges in total knee arthroplasty (TKA) and requires precision in balancing of soft tissue and implant component positioning. The surgical approach used for TKA has a determinantal impact on intraoperative soft tissue balancing, postoperative knee function, and complications. We executed a systematic review and meta-analysis of current literature, which included a maximum number of studies with quantitative analysis of all possible outcomes to substantiate the current evidence of the advantage of lateral versus medial approach in TKA for valgus knee deformity.

Methodology

We performed a meticulous primary electronic search across PubMed, Emabse, Scopus, and Cochrane Library databases, and looked for the comparative studies that evaluated the medial versus lateral approach in TKA for valgus knees. Statistical analyses were executed with RevMan-5.4.1.

Results

On the evaluation of four randomized controlled trials (RCTs), two prospective and five retrospective comparative studies, our analysis revealed a better functional outcome in terms of Knee Society Score [MD 2.24, 95% CI 0.42, 4.05; p = 0.02] with the medial approach. However, comparable results were observed for two approaches with regard to Knee Society Function [MD 0.69, 95% CI - 1.77, 3.15; p = 0.58], knee flexion range of motion (ROM) [MD 3.30, 95% CI - 1.34, 7.95; p = 0.16], overall complications [OR 0.60, 95% CI 0.27,1.34; p = 0.22], wound-related complications, infection, nerve injury, periprosthetic fracture, post-operative valgus, blood loss, duration of surgery, postoperative pain, and patellar tilt for TKA in valgus knee.

Conclusion

Evidence from the currently available published data suggests that the lateral approach, compared to the medial approach in TKA for the valgus knee, does not show clear superiority.

Does Proprioception-Based Rehabilitation Enhance Functional Outcome in Total Knee Arthroplasty? A Prospective Randomised Study

Introduction

Rehabilitation after Total Knee Arthroplasty (TKA) often includes proprioceptive exercises to prevent falls, but studies on proprioceptive training have yielded conflicting findings. This study aims to explore impact of proprioceptive training on functional performance after TKA.

Methods

Eighty patients who underwent unilateral TKA were randomly assigned to a proprioceptive exercise (PE) group or a routine exercises (RE) group. The PE group received proprioceptive exercises in addition to routine physiotherapy. Osteoarthritis Research Society Internal (OARSI) recommended tests and Oxford Knee Score (OKS) were used to assess performance and outcome at 3 and 6 months.

Results

In the 30-s chair sits test, the PE group outperformed the RE group at 3 months (13.69 vs. 9.17) and 6 months (21.07 vs. 18.63) (p < 0.001 and p = 0.030). Stair climbing favoured PE group at 3 months (8.86 vs. 16.66, p = 0.037) and 6 months (0.556 vs. 1.133, p = 0.001). At 6 months in the 40-m fast-paced walk test, the PE group had a significantly shorter time (0.308 min vs. 0.557 min, p < 0.001). Timed up and go test at 6 months favoured PE group (0.204 min vs. 0.377 min). In the 6-min walk test, the PE group covered significantly greater distances than the RE group at 3 months (589.59 vs. 346.53 m, p < 0.001) and 6 months (649.60 vs. 448.32 m, p < 0.001). OKS at 3 months was 38 ± 2.0 for PE group and 38 ± 4 for RE group (p = 1). OKS at 6 months was 42 ± 4 for PE group and 40 ± 2 for RE group (p = 0.94).

Conclusion

This study highlights the importance of proprioception-based rehabilitation in improving functional performance for TKA patients, surpassing traditional rehabilitation programmes.

Skin Temperature Following Total Knee Arthroplasty: A Longitudinal Observational Study

BACKGROUND

Total knee arthroplasty (TKA) is the most effective method of pain relief and increased functional status for end-stage knee arthritis. We aimed to assess in patients undergoing unilateral, primary TKA whether the temperature of the operated limb, compared to the nonoperative limb, remains elevated up to 1 year postoperatively.

METHODS

Using a prospective, longitudinal, observational study design, 1,094 patients were enrolled, and 889 patients completed a minimum of 4 out of 5 follow-up appointments. There were 864 patients who had a normal postoperative course, while 25 patients were deemed to have a superficial or deep infection. Skin temperatures were measured using an infrared thermometer on the operated and nonoperated knees preoperatively, at 2, 6, 12 weeks, and 1 year postoperatively. A subgroup analysis was performed on the 25 patients deemed to have a superficial or deep infection.

RESULTS

There was a statistically significant increase in skin temperature in the operated versus nonoperated knee at every follow-up, with a P < .001. However, the effect size was small at the 1-year follow-up, with a mean difference in skin temperature of 0.3 °C. In the infected subgroup, there was a statistically significant difference in skin temperature at 2, 6, and 12 weeks, with a greater difference in skin temperature between the operated and nonoperated knees (4.05 versus 3.78 °C in the noninfected). However, there was little clinical difference (0.27 °C) at 2 weeks between infected and noninfected patients.

CONCLUSIONS

This study could improve postoperative interactions between patients and surgeons. It is normal for skin temperature post-TKA to increase initially and improve over time, but it can take up to 1 year before there is little clinical difference. Because of the small difference in the rise of skin temperature between infected and noninfected patients, there is little indication that skin temperature is a reliable indicator of infection.

An Analysis of the Use of Anesthetic Blocks versus Local Anesthesia Infiltration in Primary Total Knee Arthroplasty Surgery

Objectives: The aim of this study is to analyse the efficacy of using a combined infiltration between a popliteal artery and knee cap (IPACK) anaesthetic block and a selective saphenous nerve block compared to local infiltration with anaesthetic in knee replacement surgery. Methods: A retrospective observational study was conducted. A total of 312 patients who underwent primary total knee arthroplasty in our hospital between January 2019 and December 2022 were reviewed. Local intra-articular anaesthesia was used in 207 patients and combined nerve block in 105 patients (IPACK group). The mean age in the LIA group was 72.9 years and 70.4 years in the IPACK group. There were 44% men in the LIA group and 53.3% in the IPACK group. The primary outcome was the presence of poorly controlled pain requiring rescue opioid analgesia in the postoperative period. Secondary outcomes included pain scores, range of motion and length of hospital stay. Results: There were no significant differences in the age or gender distribution of patients between the two groups. One patient treated with anaesthetic blocks required rescue analgesia with opioids, while in the LIA group this occurred in 28.5% of cases. There were statistically significant higher VAS scores in the LIA group (p < 0.001). Range of motion was slightly greater in the block group (4.6°, p < 0.05). There were significant differences in hospital stay (2.4 days in the blocks group and 2.8 days in the LIA group (p < 0.05). Conclusions: In our series, patients treated with anaesthetic blocks showed better results with similar postoperative pain control. However, further studies are needed.

One Size Does Not Fit All: Women Experience More Pain Than Men After Total Knee Arthroplasty

BACKGROUND

Multimodal pain regimens are universally applied to all patients, despite known differences in pain and responses to medication between patients of different sexes, ethnicities, and races. The purpose of this study was to understand the influence of patient sex on postoperative total knee arthroplasty pain perception as well as the efficacy of perioperative pregabalin for pain control.

METHODS

Visual analog Scales (VASs) and Knee Injury and Osteoarthritis Outcome Junior (KOOS Jr.) scores were prospectively collected for 150 patients (64 men and 86 women). Mean pain scores, delta pain scores, time to achieve minimal clinically important differences, influence of pregabalin, and opioid consumption were recorded at baseline, day of surgery, 24 hours, 48 hours, and 72 hours postoperatively, as well as postoperatively weeks 1, 2, 6, 12, and 26, and compared between women and men cohorts. This study was registered on ClinicalTrials.gov (NCT04471233).

RESULTS

The VAS pain scores for women were higher than for men at all study time points (P < 0.05). The change in VAS walking and mean KOOS Jr. scores from baseline to final follow-up at 26 weeks were not significantly different between cohorts. Both cohorts achieved VAS minimal clinically important difference by 2 weeks postoperatively. No significant differences in opioid consumption between men and women were noted during the study time periods. Women were also noted to have significantly higher raw KOOS Jr. scores than men at all-time points, except for at 26 weeks postoperatively. Interim analysis revealed no significant influence of pregabalin on VAS scores, so this arm of the study was discontinued.

CONCLUSIONS

Patient sex plays a role in perceived postoperative total knee arthroplasty pain, as women reported higher pain scores than men. We recommend not overly relying on standardized protocols, but rather instituting patient-specific pain management strategies.

Haemodynamics, side effects and safety of the combination of continuous femoral nerve block and intravenous parecoxib for pain management after Total Knee Arthroplasty: A pilot study

Background

Total Knee Arthroplasty (TKA) is a well-established surgical procedure for the treatment of knee joint diseases. This operation leads to severe acute and chronic pain, and intravenous administration of parecoxib could provide significant pain relief.

Objective

The aim of the study was to compare the hemodynamic data and safety profile of patients who received parecoxib compared to placebo following TKA.

Methods

Ninety patients were followed during this study and were randomly assigned into two equal groups. Group P received parecoxib and Group C received the placebo. Exclusion criteria included age < 40 or > 80 years, ASA III or higher, obesity (>140 kg), allergy to local anaesthetics, opioid dependence, contraindications for subarachnoid anaesthesia, femoral block or the administration of parecoxib.The haemodynamic data collected were Systolic Arterial Pressure (SAP), Diastolic Arterial Pressure (DAP), Heart Rate (HR), Oxygen Saturation (Ox-Sat), blood transfusion requirements and side effects. Recordings were performed every hour for up to 10 hours and at 15min, 4, 8, 12, 24, 36 hours postoperatively.

Results

The postoperative SAP and DAP data presented similar findings among groups (p>0.05) within the aforementioned time intervals. The postoperative HR data for both groups displayed no statistically significant difference between the two cohorts (p>0.05). Regarding the occurrence of transfusion, there is no statistically significant difference between the parecoxib and placebo cohorts. The frequency of side effects was negligible and could not be correlated with either group.

Conclusion

Therefore, parecoxib did not render any noticeable impact on the hemodynamic profile of the patients.

Different peripheral nerve blocks for patients undergoing total knee arthroplasty: a network meta-analysis of randomized controlled trials

INTRODUCTION

To comprehensively compare the effect of different peripheral nerve blocks for patients undergoing total knee arthroplasty (TKA).

MATERIALS AND METHODS

PubMed, Embase, Cochrane Library, and Web of Science were comprehensively searched. The outcomes included postoperative pain, postoperative function, adverse events, oral morphine equivalent (OME), and perioperative indicators. Network plots, forest plots, league tables and rank probabilities were drawn for all outcomes.

RESULTS

Totally 30 studies were included. For postoperative pain, continuous adductor canal block (cACB) + genicular nerve block (GNB) was most likely to be the most effective block regarding rest pain score at 24 h; cACB + GNB was most likely to result in the lowest rest pain score at 48 h; patients undergoing cACB + infiltration between the popliteal artery and the capsule of the knee (IPACK) + GNB was most likely to have the lowest motion pain score at 24 h; patients undergoing cACB + GNB was most likely to have the lowest motion pain score at 48 h. For postoperative function, patients undergoing cACB + IPACK + GNB had the highest likelihood to exhibit the shortest time in Timed Up and Go test (TUG); cACB + tibial nerve block (TNB) was most likely to be the most effective block in terms of range of motion (ROM); cACB + IPACK was most likely to be the optimal block concerning the ambulation distance.

CONCLUSION

cACB combined with IPACK/GNB may be the most favorable block after TKA, continuous blocks may be better than single-shot blocks, and combined blocks may be better than separate blocks.

Sublingual sufentanil tablet system (SSTS) versus a single shot peri-nervous injection of ropivacaine for the management of postoperative pain after total knee arthroplasty: a single-center randomized trial

INTRODUCTION

For several years, ropivacaine has been the standard-of-care for establishing postoperative femoral nerve block in total knee arthroplasty (TKA) setting and is still widely in use but new approaches such as the patient-controlled administration of sublingual sufentanil tablets system (SSTS) seem to offer good clinical results. Our aim is to compare the SSTS to single shot peri-nervous injection of ropivacaine (single shot) after TKA in terms of effectiveness in pain management and of time to recovery.

MATERIALS AND METHODS

A total of 165 patients undergoing TKA were enrolled. Eighty-four patients were randomly allocated in the SSTS group and 81 patients in the single shot group. The primary objective of the study was to evaluate performance of Timed Up and Go test. Secondary objectives were to measure the length of stay, NRS pain scale, the adherence to the prescribed plan, the joint mobility, the frequency of rescue analgesic use, side effects and patients' satisfaction.

RESULTS

Of all patients of the single shot group, 64 were withdrawn from the study as they unable to achieve pain control; only one patient was withdrawn from the SSTS group. Times for the "Timed Up and Go" test on the 3rd postoperative day were 8.4 ± 1.6 and 11.8 ± 3.6 in the SSTS group (n = 83) and single shot group (n = 17), respectively (p < .001).

CONCLUSIONS

SSTS provides better pain management when compared to peri-nervous ropivacaine single shot injection after TKA.

Auricular point acupressure for managing postoperative pain and reducing anxiety in patients with perianal abscesses

OBJECTIVE

The objective of this study is to assess the efficacy of auricular point acupressure in relieving postoperative pain and reducing anxiety among patients with perianal abscesses.

METHODS

We included 61 patients with perianal abscesses who were admitted to the Nantong First People's Hospital between July 2019 and June 2020 and were scheduled to undergo one-stage radical surgery. We divided them into the treatment group (n = 31), where patients were administered preoperative auricular acupressure targeting the bilateral Shenmen, subcortical, and other points. They were instructed to apply pressure five to six times per day, each time for about 3-5 min. Patients in the control group (n = 30) received routine preoperative preparation. The treatment duration for both groups was one week. We compared the two groups using the pain visual analog scale (VAS) scores, the use of additional postoperative analgesics, and scores on the Hamilton anxiety and depression scales pre- and post-surgery at 6 h, 24 h, 48 h, 72 h, and 1 week after surgery, as well as at the time of the first bowel movement.

RESULTS

Patients in the treatment group reported lower VAS scores than those of the control group at 48 h, 72 h, 1 week, and at the first defecation post-surgery, and the differences were statistically significant (all P < 0.05). Additional postoperative analgesics were used in seven patients in the treatment group (22.58 %) and in 10 patients in the control group (33.33 %). The difference between the two groups was not statistically significant (χ2 = 0.88, P = 0.35). Postoperative scores for the Hamilton Anxiety Rating Scale (HAM-A) and the Hamilton Depression Rating Scale (HAM-D) in the treatment group were significantly lower than those in the control group (P < 0.05).

CONCLUSION

The results of this study demonstrated that auricular point acupressure was effective in alleviating postoperative pain in patients with perianal abscesses and simultaneously reduced their postoperative psychological stress reactions. This dual effect provided both pain relief and a reduction of anxiety with fewer adverse reactions, making it a safe and effective treatment option.

Postoperative pain relief after total knee arthroplasty: A Bayesian network meta-analysis and systematic review of analgesic strategies based on nerve blocks

STUDY OBJECTIVE

A Bayesian network meta-analysis was performed to compare the analgesic efficacy of the following nerve block techniques: femoral nerve block (FNB), adductor canal block (ACB), infiltration between the popliteal artery and the capsule of the posterior knee (iPACK), and genicular nerve block (GNB) following total knee arthroplasty (TKA).

DESIGN

Systematic review and network meta-analysis (NMA).

PATIENTS AND MEASUREMENTS

We searched the Web of Science, PubMed, EMBASE, and Cochrane Library databases until September 20, 2022. Patients who were treated by any of the above four nerve block techniques (alone or in combination) after TKA were included. Patients who underwent minimally invasive knee surgery were excluded. The indicators included pain scores during rest and mobilization, opioid consumption after surgery, postsurgical mobilization function (ROM [range of motion], TUG [Timed-Up-and-Go] test) at 24 h and 48 h, and length of hospital stay. The risk of bias was assessed by the Cochrane risk of bias tool.

RESULTS

Forty-two studies involving 2857 patients were eligible for this study. This NMA suggested that ACB + iPACK was the most efficacious option for improving ambulation ability and shortening the length of hospital stay. Furthermore, ACB + iPACK was the best regimen for resting-pain and movement-pain relief (78% and 87%, respectively) and for reducing opioid consumption (90%) at 48 h. However, FNB + iPACK was the most efficacious option for relief of resting pain (42%) and reducing opioid consumption (68%) at 24 h; GNB was the most efficacious option for movement pain relief at 24 h (94%).

CONCLUSION

Considering both pain control and knee functional recovery, ACB + iPACK may be the optimal analgesic regimen for patients after TKA. At the same time, it significantly reduces pain and opioid consumption at 48 h. However, ACB + iPACK is not the recommended technique for short-term (24 h) pain control.

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD42022362322).

J-shaped association of operation duration and blood transfusion risk in patients undergoing primary total knee arthroplasty

PURPOSE

Blood transfusion is a common perioperative complication of primary total knee arthroplasty (TKA) that can lead to adverse outcomes, prolonged hospital stays, and increased medical costs. The purpose of our study was to explore the risk factors for blood transfusion and to establish whether operation duration is independently related to blood transfusion risk in patients undergoing primary TKA after adjusting for other covariates.

METHODS

This was a secondary analysis of data from a retrospective cohort study involving patients who underwent primary TKA in Singapore. The patients' baseline data, comorbidity, and surgical characteristics were collected. The independent variable was operation duration and the dependent variable was blood transfusion events. Patients were divided into three groups according to operation durations (90 and 120 min). Univariate logistic regression was used to explore the risk factors associated with blood transfusion after primary TKA. Multivariate analysis was used to assess the independent effect of operation duration on blood transfusion risk after adjusting for other covariates. Additionally, we performed subgroup analyses to identify specific groups, test the robustness of the relationships, and explore whether there were interactions between the different variables. Furthermore, restricted cubic splines (RCS) were used to identify the relationship between the two variables.

RESULTS

A total of 2,562 patients were included in the study, of whom 136 (5.61%) had a transfusion event. Operation durations were 95.55 ± 36.93 and 83.86 ± 26.29 min for blood transfused and non-transfused patients, respectively. Univariate logistic regression analysis showed that age, BMI, ASA status, Hb level, OSA, CHF, creatinine level > 2 mg/dL, and anaesthesia type were risk factors for blood transfusion. After adjusting for all covariates, multivariate logistic regression models showed that operation duration was positively associated with blood transfusion risk (odds ratio [OR] = 1.87, 95% CI = 1.174-2.933, P = 0.007). Compared to patients with an operation duration of less than 90 min, those with an operation duration of more than 120 min had a 2.141-fold increased risk of blood transfusion (OR = 2.141, 95% CI = 1.035-4.265, P = 0.035). Stratified analysis results showed that the association persisted in patients aged > 50 years, Chinese, BMI > 30 kg/m 2, Hb level > 11 g/dL, ASA status levels 2 and 3, general anaesthesia, and unilateral primary TKA. A non-linear (P-non-linear = 0.30) and J-shaped relationship was identified. The risk of transfusion increased as the operation duration decreased or exceeded the inflection point (73.2 min).

CONCLUSION

Our study demonstrated a non-linear and J-shaped relationship between operation duration and blood transfusion events in patients undergoing primary TKA. Blood transfusion risk was the lowest when the operation duration was 73.2 min. A shorter operation duration implies irregular surgical procedures and incomplete intraoperative haemostasis, leading to increased perioperative blood loss and blood transfusion. These results will be useful for clinical decision-making.

Exploring the factors affecting the readiness for hospital discharge after total knee arthroplasty: A structural equation model approach

AIM

To investigate the factors that influence readiness for hospital discharge in Chinese patients after total knee arthroplasty and to identify priorities for nursing interventions.

DESIGN

A cross-sectional study.

METHODS

From January to August 2022, data were collected from 339 patients at two tertiary A-level hospitals in Jinan, Shandong Province. SPSS 26.0 and Mplus 8.3 software were used for statistical analysis.

RESULTS

Results from multiple linear regression showed that patients' age, residence status, education level, knee pain during sleep, quality of discharge teaching, self-efficacy for rehabilitation, pain control knowledge, and social support were factors influencing their readiness for hospital discharge. The results of the structural equation model had shown that there were also indirect effects of the education level, knee pain during sleep, quality of discharge teaching, and pain control knowledge.

CONCLUSION

Patients' readiness for hospital discharge needs further improvement, hence physicians and nurses should judiciously allocate medical resources and concentrate their efforts on high-risk groups characterized by low readiness for hospital discharge.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

This study underscores the importance of physicians and nurses prioritizing key factors such as age, residency status, education level, and social support in total knee arthroplasty patients to enhance their readiness for hospital discharge. By implementing targeted discharge planning, effective pain management, and comprehensive rehabilitation education, healthcare providers can improve patient outcomes.

IMPACT

This study identified key factors influencing readiness for hospital discharge in total knee arthroplasty patients, guiding targeted nursing interventions to improve post-operative care.

REPORTING METHOD

STROBE.

PATIENT OR PUBLIC CONTRIBUTION

The participants recruited for this study were actively engaged in the data collection process.

TOTAL DİZ PROTEZİ CERRAHİSİ SONRASI TELE-REHABİLİTASYON PROGRAMININ ETKİLERİNİN ARAŞTIRILMASI: RANDOMİZE KONTROLLÜ ÇALIŞMA

Amaç: Çalışmamızın amacı; total diz protezi (TDP) cerrahisi sonrası tele-rehabilitasyon programı (TR-FTR) ve yüz yüze fizik tedavi ve rehabilitasyon programı (YY-FTR) alan bireylerde uygulanan protokolleri fiziksel ve fonksiyonel parametreler açısından karşılaştırmak ve tele-rehabilitasyon (TR) hizmeti alanların bu hizmetten memnuniyetlerini değerlendirmekti. Yöntem: TDP cerrahisi geçirmiş 37 birey randomize olarak TR-FTR ve YY-FTR grubu olacak şekilde ikiye ayrıldı. Çalışmaya dahil olan bireylerin diz eklem hareket açıklığı (D-EHA) universal gonyometre ile; fiziksel performansları “Zamanlı Kalk ve Yürü Testi”, “6 Dakika Yürüme Testi”, “5 Tekrarlı Otur-Kalk Testi” ile; fonksiyonellikleri “Western Ontario ve McMaster Üniversiteleri Osteoartrit İndeksi” (WOMAC) ile, egzersiz programına uyumu ise “Egzersize Uyum Derecelendirme Ölçeği” ile değerlendirildi. TR-FTR’ye katılanlara “Tele-Sağlık Kullanılabilirlik Anketi” ve “Tele-Tıp Memnuniyet Anketi” uygulandı. Her iki gruba uygulanan testler ve anketler yüz yüze olarak yapıldı. Sonuçlar: Her iki grubun da tedavi sonrası D-EHA aktif ve pasif ölçümlerinde (pasif diz ekstansiyonu hariç) (p

Comparison ultrasound-guided adductor canal block and surgeon-performed block for pain management after total knee arthroplasty: a prospective randomized controlled study

OBJECTIVE

Adductor canal block (ACB) is widely performed for postoperative analgesia for total knee arthroplasty (TKA). The aim of this study is to compare surgeon-assisted and anesthesiologist-assisted (ultrasound-guided) adductor blocks in terms of postoperative analgesic efficacy.

METHODS

This study was designed as a double-blind, prospective and randomized trial. A total of 240 participants were randomly allocated to three groups: one where the surgeon performed the adductor canal block (ACBs), another where it was conducted by an anesthetist with ultrasound guidance (ACBa), and a third group without the adductor block. The follow-up management after the Total Knee Arthroplasty (TKA) procedure occurred on the first, third, and tenth days, as well as the twelfth week. Outcome measures comprised pain assessment using the Visual Analog Scale (VAS) and monitoring opioid analgesic consumption.

RESULTS

No significant differences in demographic profiles were observed between the groups. Groups ACBa and ACBs exhibited significantly lower VAS scores compared to the control group at both 3 and 12 h after surgery, with group ACBa showing the lowest VAS scores among all groups. However, at 1 day, 3 days, 10 days and 12 weeks after surgery, there was no significant difference in VAS scores between the ACBa and ACBs groups. On the first three days, the ACBa group had the lowest opioid consumption and the lowest total opioid consumption. The differences in VAS scores between the groups began to decrease on the first day after surgery.

CONCLUSION

The adductor canal block (ACB) has been demonstrated to be an effective method of reducing pain in patients undergoing total knee replacement (TKR) in the postoperative period. Nevertheless, despite the pronounced impact that ACB performed by an anesthesiologist under ultrasound guidance has on VAS scores according to intraoperative ACB by surgeons, its effect on clinical outcomes has not been demonstrated.

TRIAL REGISTRATIONS

This study was retrospectively registered with the Clinical Trials Registry Platform on July 31, 2024 (NCT06533085).

Analgesic eluting bone cement: A novel approach for targeted pain management in total knee arthroplasty - An in-vitro study

BACKGROUND

The average rate of patient dissatisfaction following total knee arthroplasty (TKA) is 10%. Multi-modal analgesia is the present standard of pain management after TKA. Studies show that with multi-modal analgesia, approximately 60% of patients experience severe knee pain following surgery, while around 30% experience moderate pain. To date, there is no literature available on targeted pain management using bone cement.

OBJECTIVES

To investigate the feasibility of incorporating anti-inflammatory medications and identify the analgesic with the best release pharmacokinetics from bone cement for application in pain management.

METHODS

In an in-vitro study, 100 mg of five drugs (aceclofenac, diclofenac, naproxen, paracetamol and methyl prednisolone) were incorporated into bone cement (Palacos). Cement cubes holding each drug were made and allowed to harden for 30 min. Each drug-containing cube was placed in a beaker with saline for 72 h. Fractions of 10 ml were collected at 0, 6, 24, 48 and 72 h and analysed using high-pressure liquid chromatography to measure the percentage release of the drug from bone cement.

RESULTS

Naproxen showed superior elution from bone cement, with 10.9% at 24 h and 9.08% at 72 h. Paracetamol showed 4.9% at 24 h and 3.78% at 72 h, aceclofenac 0.2% at 24 h and 0.4% at 72 h, diclofenac 3.03% at 24 h and 1.99% at 72 h, and methylprednisolone 0.26% at 24 h and 0.32% at 72 h.

CONCLUSIONS

Polymethylmethacrylate bone cement can elute analgesics in vitro. Among the five drugs studied, naproxen had the best release kinematics from polymethylmethacrylate bone cement. Analgesic eluting bone cement is a novel approach for targeted postoperative pain management in TKA.

Evaluation of reduced ('Lite') compression versus brief bandaging to manage post-operative pain after total knee arthroplasty surgery; a single-centre randomised controlled trial

PURPOSE

Investigate efficacy of reduced compression bandage for the control of pain after total knee arthroplasty.

PATIENTS & METHODS

Prospective, single-centre, randomised controlled trial involving data for 56 out of 94 consented patients; 29 standard care versus 27 Andoflex TLC Calamine Lite. Comparison of standard care (non-compression bandage applied for up to one day) versus Andoflex TLC Calamine Lite (25-30 mmHg) two-layer compression bandage worn for five days. Outcomes measured with validated pain (McGill, 10-cm visual scale) and functionality (KOOS) tools.

RESULTS

At day 5 post-surgery, the median pain level was 3.0 cm vs 4.0 cm (p-value 0.47, Mann-Whitney U test) respectively. Generic pain levels, pain types, and knee functionality did not differ between the interventions at days 3/5/12 and week 6 post-surgery. An exception was the degree of 'tender' pain at day 12, which was significantly lower in the Andoflex TLC Calamine Lite arm (p-value 0.041, Mann-Whitney U test). Binary logistic regression analysis showed that application of Andoflex TLC Calamine Lite, administration of oxycodone, and male sex were all significantly associated with less 'tender' pain.

CONCLUSION

Reduced compression bandaging does not affect overall pain levels post knee arthroplasty surgery, but may alleviate pain experienced as 'tender', highlighting the different types of pain that may be experienced. Patients' need for, and the use of, opioid medication (oxycodone) is a significant confounding variable when assessing adjuvant therapy to control pain. The applicability of reduced compression bandaging may therefore be limited and is less efficient than medical pain control.

Comparison the Effect of Rehabilitation at Home and Outpatient Physiotherapy after Total Knee Arthroplasty Surgery on Quality of Life and Knee Function: A Clinical Trial Study

Background

Primary total knee arthroplasty (TKA) is an effective procedure to better function and relief the pain in advanced osteoarthritis patients. This study aimed to evaluate the effectiveness and safety of outpatient clinic-based setting of physiotherapy versus home-based rehabilitation (HBR) for functional recovery immediately after primary TKA procedure.

Materials and Methods

This randomized clinical trial study was conducted on patients underwent TKA in 2021-2022. Participants were randomly allocated to either "usual care" or a "home-based rehabilitation" in a 1:1 ratio. The primary outcome measurement of this study was the Knee Society Score (KSS). The secondary outcome was patient quality of life using the 36-item Short Form Survey Instrument (SF-36). Data were entered into the SPSS software 25 and analyzed.

Results

In this study, 80 patients who underwent TKA in equal proportion in two outpatient physiotherapy (36 women; average age 64.37 ± 5.12 years) and home rehabilitation (33 women; average age 62.4 ± 4.87 years) groups were examined. The findings our study showed that after the intervention (3 and 5 months after the operation), there was no significant difference between the two groups in terms of the quality of life (total score) (P > 0.05). KSS had no significant difference between the two groups (P > 0.05).

Conclusion

This randomized controlled trial found no significant differences in the outcomes of rehabilitation using either a HBR or a traditional outpatient physiotherapy model.

IPACK Block Efficacy for Acute Pain Management after Total Knee Replacement: A Review

PURPOSE OF REVIEW

Patients often experience a significant degree of knee pain following total knee replacement (TKR). To alleviate this pain, nerve blocks may be performed such as the adductor canal block (ACB). However, ACBs are unable to relieve pain originating from the posterior region of the knee. A new type of nerve block known as the IPACK block may be used in conjunction with ACBs as it is designed to inhibit nerve branches innervating this area. In this article, we examine the rationale behind the IPACK procedure, how it is performed, and clinical trials examining its efficacy.

RECENT FINDINGS

5 of the 7 clinical trials examined in this article showed the IPACK + ACB block to show superior efficacy in treating pain following TKR compared to other blocks. These blocks included PMDI+ACB, SPANK+ACB, PAI+ACB, ACB alone, and SCAB. 2 of the 7 clinical trials showed the IPACK + ACB to be less effective in managing patients pain following TKR compared to other blocks which included the CACB and 4 in 1 block. In most instances, the IPACK + ACB showed superior efficacy in managing patients' pain following TKR when compared to other types of nerve blocks. This was determined by measuring usage of opioids, reported postoperative pain, and length of hospital stays following TKR. Thus, we suppose the IPACK block may be used in conjunction with the ACB to effectively reduce patient's pain following TKR.

Effect of Topical Application of an NSAID Lateral to the Incision on Postoperative Pain Following Unicompartmental Knee Arthroplasty: A Double-Blind Randomized Controlled Trial

OBJECTIVE

How to minimize postoperative pain following knee replacement surgery has been a great challenge. This study was performed to evaluate the effect of applying a topical nonsteroidal anti-inflammatory drug (NSAID) lateral to the incision for postoperative pain following unicompartmental knee arthroplasty (UKA).

METHODS

The randomized controlled trial enrolled 100 patients from August 2023 to January 2024. One hundred patients who underwent UKA were randomized into two groups. The intervention group received a topical NSAID lateral to the incision postoperatively, and the control group received a placebo lateral to the incision postoperatively. The primary outcome measures were the amount of opioid consumption and the visual analogue scale (VAS) score (12, 24, 36, 48, and 72 h after operation) for pain. The secondary outcome measures were the American Knee Society Score (AKSS, preoperation and 1-month follow-up after operation), the time of first analgesic demand, side effects of opioids, operation time, postoperative stay, surgery-related complications, and postoperative incision healing grade. Independent sample t test and paired sample t test were used to compare continuous data. Chi-square test and Fisher's precision probability tests were used to analyze the categorical data.

RESULTS

Ninety-eight patients (intervention group, 48 patients; control group, 50 patients) were analyzed. Opioid consumption was significantly lower in the intervention group than in the control group during the first 12 h, 12 to 24 h, and 24 to 48 h postoperatively (p < 0.05). The VAS score for pain within 72 h postoperatively was significantly lower in the intervention group than in the control group (p < 0.05). There was no significant difference in the AKSS, operation time, postoperative stay, complications, or postoperative incision healing grade between the two groups. The time of first analgesic demand for patient-controlled analgesia was significantly later in the intervention group than in the control group (p < 0.05). There were fewer side effects of opioids in the intervention group (8.3%) than in the control group (18.0%).

CONCLUSION

Postoperative application of topical NSAIDs lateral to the incision is an effective and safe method for pain management after UKA, helping to decrease the pain score and reduce opioid consumption postoperatively with no increase in side effects.

Clinical Efficacy of Intra-articular Tranexamic Acid Injection in the Management of Hemophilia with Total Hip Arthroplasty: A 24-month Retrospective Cohort Study

OBJECTIVE

Total hip arthroplasty (THA) effectively treats end-stage hemophilic hip arthropathy. Given hemophilia's unique characteristics, perioperative bleeding remains a significant risk for patients undergoing THA. Tranexamic acid (TXA), an efficient antifibrinolytic agent, may benefit the outcomes of THA for patients with hemophilia (PWH). This study aims to explore the clinical efficacy of intra-articular injection of TXA in treating perioperative bleeding in PWH and assess its additional clinical benefits.

METHODS

The retrospective study comprised data of PWH who received THA from January 2015 to December 2021 in the research center. A total of 59 individuals were included in the study, divided into a TXA group (n = 31) and a non-TXA group (n = 28). We compared various parameters, including total blood loss (TBL), visible blood loss (VBL), occult blood loss (OBL), intraoperative coagulation factor VIII (FVIII) consumption, perioperative total FVIII consumption, hemoglobin (HB), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), length of hospital stay, hospitalization costs, length of surgery, total protein, activated partial thromboplastin time (APTT), D-dimer, rate of joint swelling, hip joint range of motion (ROM), visual analogue scale (VAS), and Harris hip joint function scale (HHS) between the two groups. Follow-up assessments were conducted for up to 24 months. A Student's t test was utilized for the statistical analysis.

RESULTS

This study demonstrated that intra-articular TXA effectively reduced TBL (1248.19 ± 439.88 mL, p < 0.001), VBL (490.32 ± 344.34 mL, p = 0.003), and OBL (757.87 ± 381.48 mL, p = 0.004) in PWH who underwent THA. TXA demonstrated effectiveness in reducing VAS scores on POD1, POD7, and POD14 and joint swelling rates on POD1, POD7, POD14, and at discharge (p < 0.05). Additionally, the TXA group achieved higher HHS ratings at all follow-up time points (p < 0.05), showing superior hip joint mobility, lower postoperative inflammation levels, reduced factor VIII consumption during surgery, and less postoperative nutritional loss. No statistically significant differences were observed between the two groups in terms of hospital stay, hospitalization costs, surgery duration, and coagulation indicators.

CONCLUSION

Intra-articular injection of TXA reduces perioperative bleeding in PWH undergoing THA while also improving joint mobility, post-operative rehabilitation, and quality of life. This may provide value for the future application of TXA in PWH.

Eliminating Extended-Release Opioids from a Postoperative Pain Protocol for Total Knee Replacement Patients

PURPOSE

To determine whether the elimination of extended release (ER) opioids in the multimodal medication regimen of total knee replacement (TKR) patients resulted in improved patient outcomes.

DESIGN

Retrospective cohort quality improvement.

METHODS

This project utilizes a retrospective chart review to evaluate an institution's current postoperative pain protocol. The outcomes of interest include mean hospital length of stay, discharge disposition, mean pain score, antiemetic use, mean opioid dose used, and number of opioid discharge prescriptions.

RESULTS, CONCLUSIONS, AND CLINICAL IMPLICATIONS

Sixty patients were reviewed with a mean age at 70 years for both the pre-protocol (n = 36) and post-protocol groups (n = 34). There was a reduction in antiemetic use, t(59) = 2.2, p = .03 and length of stay, t(58) = 1.0, p = .33, and more discharges to home than rehab, x2 = 60, p < .001. All patients received 30 tablets of only one opioid prescription upon discharge with no refill, either oxycodone-IR (82%, n = 49), hydromorphone (5%, n = 3), or tramadol (12%, n = 7). The project, aimed to reduce opioid overprescription and overconsumption, has the potential to improve prescribing practices, promoting patient safety and healthcare quality by supporting the current guidelines that recommend against using ER opioids for the study population.

Methodological Assessment of the 100 Most-Cited Articles in Total Knee Arthroplasty in the Last Decade Compared to the All-Time List

BACKGROUND

Recent advances in total knee arthroplasty (TKA) have been driven by a growing focus on evidence-based medicine. This transition is reflected in the critical appraisal of both, the quality of work and the potential impact on the orthopedic community. The purpose of our study was to (1) identify the top 100 most-cited articles in TKA in the last decade and from all-time, and (2) compare methodological rigor of the most-cited articles in TKA in the last decade to articles all-time by level of evidence.

METHODS

The top 100 cited articles were recorded for manuscripts from the last decade, January 1, 2012 to December 31, 2022, and manuscripts from all-time for TKA. We collected authors, year of publication, journal of the article, country of origin of authors, article type (basic science article, clinical research article), level of evidence, methodological index for non-randomized studies score, physiotherapy evidence database scale, and citation density (total citations/years published).

RESULTS

The largest number of studies for all-time TKA (53.0%) and decade TKA (42.0%) were Level III. The average methodological index for non-randomized studies score for comparative studies was 18.7 for all-time TKA and 20.7 for decade TKA (P < .001). The average physiotherapy evidence database score was 6.1 for all-time TKA and 8.1 for decade TKA (P > .05). The highest citation density for all-time TKA was 111 and for past decade was 63. The number of level II studies in TKA increased from 19.0% from all time to 38.0% from the last decade (P < .05).

CONCLUSIONS

Our findings of improved methodologies over time reflect positive steps toward evidence-based practice in TKA. A continued focus on producing methodologically sound studies may guide evidence-based clinical decision-making.

Online Learning to Improve Nurses' Knowledge, Attitudes, and Self-Efficacy About Managing Postoperative Pain in Older Adults

BACKGROUND

Older adults undergoing total knee arthroplasty may develop chronic pain without effective postoperative pain management. Increasing nurses' knowledge, changing their attitudes, and developing their pain management self-efficacy could improve the effectiveness of pain management.

AIM

To determine the effectiveness of an online learning program to help registered nurses to manage postoperative pain in older adults undergoing total knee arthroplasty.

DESIGN

A quasi-experimental pre-test-post-test design with intervention and control groups.

METHOD

Six inpatient units were randomly selected at a large tertiary care medical center. Sixty nurses were evenly divided between intervention and control groups to participate in online learning about postoperative pain management in patients undergoing total knee arthroplasty. The content was based on Kolb's experiential learning theory. Data were collected on nurses' knowledge and attitudes toward pain management and pain management self-efficacy at baseline and after completion. Data were analyzed using descriptive statistics, chi-square tests, paired t-tests, and independent t-tests.

RESULTS

The knowledge and attitudes about pain management and pain management self-efficacy toward older adults undergoing total knee arthroplasty of nurses in the intervention group significantly improved compared to the baseline and were also significantly higher than in the control group.

CONCLUSIONS

An online learning program improves nurses' understanding and ability to manage pain in older adults undergoing total knee arthroplasty. This was therefore an effective learning method.

Genicular nerve radiofrequency ablation: a systematic review of application for perioperative pain control in total knee arthroplasty and as treatment for chronic pain in well-appearing total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a successful treatment for end-stage osteoarthritis, yet some patients still experience postoperative pain. Genicular nerve radiofrequency ablation (GNRFA) has become a potential modality to address pain in TKA. This systematic review aims to critically analyze the applicability of GNRFA in perioperative pain control prior to TKA, as well as a treatment modality for chronic painful well-appearing TKA.

METHODS

PubMed, Medline, EMBASE, Google Scholar, Scopus, and COCHRANE databases, as well as the ClinicalTrials.gov register, were reviewed. The search included randomized controlled trials and cohort studies. The sample population focused on two cohorts; those who underwent TKA and utilized intentional GNRFA as a perioperative pain control modality, and those utilizing the treatment modality for chronic pain in well-appearing TKA. GNRFA was the intervention studied, and postoperative outcomes were compared with the control group, which consisted of those not receiving GNRFA.

RESULT

Eight total publications were identified as relevant to this search. Among the pre-TKA studies, there was variability in results; these inconsistencies were attributed to a lack of standardization, especially with regard to type, timing, and targeted nerves with ablation. Likewise, while the results were improved among the population with chronic painful TKA receiving GNRFA, these inconsistencies still existed.

CONCLUSIONS

Current evidence suggests GNRFA as a possible pre-TKA intervention to potentially minimize opioid consumption, patient-reported pain, length of stay, and increased range of motion and activity. However, the short-lived duration in the setting of chronically painful well-appearing TKA represents a major barrier that warrants further investigation. Limitations include small sample size, heterogeneity, lack of standardization of techniques among studies, and lack of direct comparison and meta-analysis. Further research should focus on the standardization of technique as well as analyzing various patient and health-system-related factors that correlate with sustained positive outcomes.

Transcutaneous electrical acupoint stimulation for rehabilitation after total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Rehabilitation after total knee arthroplasty (TKA) has become an indispensable part of the treatment strategy for degenerative joint disease. Despite some current research demonstrating efficacy of transcutaneous electrical acupoint stimulation (TEAS) for post-TKA rehabilitation, the evidence is not conclusive.

OBJECTIVE

To systematically assess the evidence supporting TEAS for rehabilitation after TKA.

METHODS

A literature search of the PubMed, Embase, The Cochrane Library, Chinese National Knowledge Infrastructure, Chinese Biomedical Literature Database, Wanfang, and Chinese Scientific Journal Data databases for relevant studies published up to October 16, 2023, was performed. Main indicators included visual analog scale (VAS) and functional scores; secondary indicators included range of motion (ROM), interleukin-6 (IL-6) and C-reactive protein (CRP) levels, and analgesia-related adverse events. Risk of bias was evaluated using the Cochrane Tool, and meta-analysis was performed using Review Manager version 5.4.

RESULTS

Twenty RCTs with 1295 participants were included. TEAS improved several outcomes compared to control groups. The TEAS group had significantly greater pain reduction at postoperative 6 h, 12 h, 24 h, 48 h, 72 h, 7 days, and 14 days. Moreover, TEAS significantly improved the Hospital for Special Surgery Knee Score, Knee Society Score, and ROM. Patients who underwent TEAS exhibited a lower incidence of analgesia-related adverse events and lower IL-6 and CRP levels.

CONCLUSIONS

Available evidence indicates that the application of TEAS in patients undergoing TKA is related to postoperative pain alleviation, functional improvement, and fewer adverse events associated with analgesia.

Saw-box osteotomy versus reamer-box osteotomy in posterior stabilized total knee arthroplasty: a retrospective study of an average five year follow-up

PURPOSE

The purpose of this study is to compare the difference of results between two methods of femoral box osteotomy adopted by two designs of posterior stabilized total knee prostheses.

PATIENTS AND METHODS

Retrospective analysis of the results of two groups of patients operated upon using two primary PS TKA systems, PFC Sigma (DePuy Synthes, Johnson and Johnson®) and Genesis II prosthesis (Smith and Nephew®), with an average of five year follow-up was done. Group 1 included 152 knees in 121 patients and group 2 included 122 knees in 111 patients. The average follow-up period in both groups was five years. The box osteotomy method depends on bone saw in group 1, and bone reamer in group 2.

RESULTS

The KSS score of group 2 was better in the first six months postoperatively. Then, no significant differences were seen in the remaining follow-up visits. The risk of periprosthetic fractures was significantly higher in group 1 (p-value 0.040). Survival analysis showed a significantly shorter time for reoperation in group 1 than in group 2 as described by log-rank test, (p < 0.006).

CONCLUSION

The method of box cutting has an impact on the function and longevity of posterior stabilized primary knee implants. The risk of periprosthetic fractures can be reduced by proper patient selection, decreasing the box sizes, and development of more "controlled" box osteotomy instruments.

A Network Meta-Analysis of Randomized Controlled Trials Assessing Intraoperative Anesthetic Therapies for Analgesic Efficacy and Morphine Consumption Following Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to compare intraoperative anesthetic therapies for total knee arthroplasty (TKA) regarding postoperative analgesic efficacy and morphine consumption by conducting a systematic literature search.

METHODS

Randomized controlled trials of TKA using various anesthetic therapies were identified from various databases from conception through December 31, 2021. A network meta-analysis of relevant literature was performed to investigate which treatment showed better outcomes. In total, 40 trials were included in this study.

RESULTS

Surface under the cumulative ranking curve showed local infiltration anesthesia (LIA) with saphenous nerve block (SNB) to produce the best pain relief on postoperative days (PODs) 1 and 2 and the best reduction of morphine consumption on PODs 1 and 3. However, femoral nerve block showed the largest effect on pain relief on POD 3, and liposomal bupivacaine showed the largest effect on reduction of morphine consumption on POD 2.

CONCLUSIONS

According to this network meta-analysis, surface under the cumulative ranking curve percentage showed that LIA with SNB provided the best analgesic effect after TKA. Furthermore, patients receiving LIA with SNB had the lowest consumption of morphine. Although femoral nerve block resulted in better pain relief on POD 3, LIA with SNB could be selected first when trying to reduce morphine consumption or increase early ambulation.

Intraoperative intravenous versus periarticular injection of glucocorticoids in improving clinical outcomes after total knee arthroplasty: A prospective, randomized and controlled study

BACKGROUND

Glucocorticoids have been widely used in perioperative period for postoperative pain relief after total knee arthroplasty (TKA). However, the optimal administration protocols of glucocorticoids remain controversial. This study aims to compare the efficacy of glucocorticoids between intravenous and periarticular injection on clinical outcomes.

METHODS

A total of 114 patients were randomly assigned to intravenous (IV) group (n = 57) and periarticular injection (PI) group (n = 57). The IV group received 10 mg dexamethasone intravenously and the PI group received periarticular injection of 10 mg dexamethasone during the procedure. The clinical outcomes were assessed using visual analogue scale (VAS), knee society score (KSS), range of motion (ROM), knee swelling, inflammation markers and complications after TKA.

RESULTS

The VAS score during walking at 2nd day postoperatively was lower in the PI group compared with the IV group (2.08 ± 1.45 vs 2.73 ± 1.69, p = .039), and there was no significant difference at the other time points of VAS score in two groups. The inflammation markers, knee swelling, knee ROM and KSS score were not statistically different. Vomiting and other complications occurrence were not significantly different between the two groups.

CONCLUSIONS

Intraoperative periarticular injection of glucocorticoids has similar analgesic effect compared to intravenous in the postoperative period following TKA and may be even more effective on the second postoperative day. In addition, periarticular injection of glucocorticoids does not impose an excess risk or complication on patients.

Designing and developing a nature-based virtual reality with heart rate variability biofeedback for surgical anxiety and pain management: evidence from total knee arthroplasty patients

OBJECTIVES

Total knee arthroplasty (TKA) is one of the most common joint surgeries, with over a million procedures performed annually in the US. Over 70% of patients report moderate to high pain and anxiety surrounding TKA surgery, and 96% are discharged with an opioid prescription. This population requires special attention as approximately 90% of TKA patients are older adults and one of the riskiest groups prone to misusing opioids. This study aimed to develop and compare the efficacy of nature-based virtual reality (VR) with heart rate variability biofeedback (HRVBF) to mitigate surgical pain and anxiety.

METHODS

This randomized control trial recruited 30 patients (mean age = 66.3 ± 8.2 years, 23 F, 7 M) undergoing TKA surgery and randomly assigned to a control, 2D video with HRVBF, or VR with HRVBF group. A visual analog scale (VAS) was used to measure pain levels before and after the intervention. In addition, a second VAS and the State-Trait Anxiety Inventory (STAI) were used to measure anxiety before and after the intervention. Electrocardiogram (ECG) was used to continuously measure HRV and respiration rate in preoperative and postoperative settings.

RESULTS

VR and 2D-video with HRVBF decreased pain and anxiety post-intervention compared with the control group, p's <.01. On analyzing physiological signals, both treatment groups showed greater parasympathetic activity levels, and VR with HRVBF reduced pain more than the 2D video, p < .01.

CONCLUSIONS

Nature-based VR and 2D video with HRVBF can mitigate surgical pain and anxiety. However, VR may be more efficacious than 2D video in reducing pain.

Irradiation Behavior of Analgesic and Nonsteroidal Anti-Inflammatory Drug-Loaded UHMWPE for Joint Replacement

Local delivery of pain medication can be a beneficial strategy to address pain management after joint replacement, as it can decrease systemic opioid usage, leading to less side and long-term effects. In this study, we used ultrahigh molecular weight polyethylene (UHMWPE), commonly employed as a bearing material for joint implants, to deliver a wide set of analgesics and the nonsteroidal anti-inflammatory drug tolfenamic acid. We blended the drugs with UHMWPE and processed the blend by compression molding and sterilization by low-dose gamma irradiation. We studied the chemical stability of the eluted drugs, drug elution, tensile properties, and wear resistance of the polymer blends before and after sterilization. The incorporation of bupivacaine hydrochloride and tolfenamic acid in UHMWPE resulted in either single- or dual-drug loaded materials that can be sterilized by gamma irradiation. These compositions were found to be promising for the development of clinically relevant drug-eluting implants for joint replacement.

Pain Control Associated With Gabapentinoid Prescription After Elective Total Knee Arthroplasty

BACKGROUND

Gabapentinoid (GABA) prescribing has substantially increased as a nonopioid analgesics for surgical conditions. We examined the effectiveness of GABA use for postoperative pain control among patients receiving total knee arthroplasty (TKA).

METHODS

This retrospective cohort study using 2016 to 2019 data from a 20% national sample of Medicare enrollees included patients aged 66 and over years who received an elective TKA, were discharged to home, received home health care, and had both admission and discharge assessments of pain (n = 35,186). Study outcomes were pain score difference between admission and discharge and less-than-daily pain interfering with activity at discharge. Opioid and GABA prescriptions after surgery and receipt of nerve block within 3 days of surgery were also assessed.

RESULTS

There were 30% of patients who had a pain score decrease of 3 to 4 levels and 55.8% had pain score decreases of 1 to 2 levels. In multivariable analyses, receiving a nerve block was significantly associated with pain score reduction. A GABA prescription increased the magnitude of pain score reduction among those receiving a nerve block. Results from inverse probability weighted analysis with propensity score showed that coprescribing of GABA and low-dose opioid was associated with significantly lower pain scores.

CONCLUSIONS

Post-TKA opioid use was not associated with pain score reduction. Receiving a nerve block was associated with a modest pain score reduction. Co-prescribing GABA with low-dose opioid or receiving a nerve block was associated with increasing magnitudes of pain reduction. Further research should identify alternatives to opioid use for managing postoperative TKA pain.

Efficacy and safety of continuous nursing in improving functional recovery after total hip or knee arthroplasty in older adults: A systematic review

Objective

This systematic review was conducted to evaluate the efficacy and safety of continuous nursing care for the recovery of joint function in older adults with total hip or knee arthroplasty.

Methods

Randomized controlled trials and cohort studies of continuous nursing in older patients after joint replacement were searched from the database of Cochrane Library, Web of Science, PubMed, and Embase from their establishment to October 25, 2023. After literature screening, two researchers completed data extraction, and the risk of bias was assessed using the Cochrane risk-of-bias tool. The risk analysis included in cohort studies was based on the Newcastle-Ottawa Scale (NOS).

Results

The study included a total of 15 articles, comprising 34,186 knee and hip replacement patients. In this review, the effects of continuous nursing on the recovery of joint function of knee replacement and hip replacement in older adults were classified and discussed. Continuous nursing interventions targeted for total hip replacement could greatly increase the range of joint mobility, enhance muscle strength during hip movements like flexion, extension, and abduction, maintain joint stability, relieve pain, improve daily activities, and lower the risk of complications. For older patients with knee arthroplasty, continuous nursing programs could markedly improve knee motion range, joint flexion, joint stability, daily activities, and pain management. Despite the implementation of interventions, the incidence of complications caused by total knee replacement did not decrease. Out of all the studies reviewed, only one used a theoretical framework for interventions provided to patients during the postoperative period of hip arthroplasty. The overall quality of the included studies was very high.

Conclusion

Continuous nursing can effectively improve the joint function of older patients after joint replacement. However, its effectiveness in terms of clinical outcomes, patient satisfaction, and medical cost of associated continuous nursing needs to be further clarified. In addition, continuous nursing has no significant advantage in the safety of postoperative complications and readmission rates in older adults after knee joint replacement. To enhance the efficacy and safety of continuous nursing effectively, it is crucial to refine the continuous nursing program in the future, thereby elevating the quality of nursing services.

Comparing Apotel and Remifentanil for Multimodal Patient-Controlled Analgesia in Postoperative Pain Management Following Total Knee Arthroplasty Surgery: A Randomized Controlled Trial

Background

Total knee arthroplasty (TKA) is a standard surgical procedure for individuals with debilitating knee arthritis. Effective postoperative pain management is essential for successful recovery, although traditional opioid-based methods have limitations.

Objectives

This study aimed to compare the efficacy of Apotel and remifentanil patient-controlled analgesia in managing postoperative pain after TKA.

Methods

This double-blind, randomized, controlled clinical trial took place at Amir-al-Momenin and Qods Hospitals in Arak, Iran, spanning from June 2022 to September 2023. Sixty-two eligible patients scheduled for knee joint replacement were randomly assigned to receive either Apotel (Group A) or remifentanil (Group R) as part of multimodal analgesia administered via a pain pump for postoperative pain relief in TKA. The study assessed hemodynamic parameters, pain levels (measured using the Visual Analog Scale), analgesic duration, and narcotic consumption. Statistical analyses were performed using SPSS v.27 and Plotly.

Results

Subjects exhibited no statistically significant differences in age, gender distribution, duration of surgery, or anesthesia. The hemodynamic status assessment in the recovery room showed no significant differences in SPO2, PR, or MAP between the groups. However, remifentanil demonstrated superior effectiveness in reducing pain over 24 hours post TKA surgery compared to Apotel, as evidenced by lower average Visual Analog Scale (VAS) scores (P < 0.001), longer duration without the need for narcotic painkillers (P < 0.001), and lower cumulative opioid analgesic consumption in Group R (P < 0.001).

Conclusions

Remifentanil demonstrates superior pain control in a multimodal pain management approach compared to Apotel, providing sustained pain reduction over 24 hours post-surgery. Moreover, remifentanil offers longer-lasting pain relief and results in lower cumulative narcotic painkiller consumption compared to Apotel.