Randomised controlled study comparing general and spinal anaesthesia with and without a tourniquet on the outcomes of total knee arthroplasty: study protocol

Fat tissue is a poor predictor of 1 year outcomes after total knee arthroplasty: A secondary analysis of a randomized clinical trial

BACKGROUND AND OBJECTIVE

Obesity may increase the risk of adverse events after total knee arthroplasty (TKA). Although body mass index (BMI) is commonly used in categorizing obesity, its accuracy is limited. Body fat percentage (BFP) might indicate adiposity status and predict arthroplasty-related outcomes better than BMI. We investigated whether BFP is predictive of TKA-related outcomes.

METHODS

In this secondary analysis, BFP was measured preoperatively from 294 participants of a randomized trial that investigated the effects of tourniquet and anesthesia methods on TKA. Data concerning in-hospital assessments and events were collected. Knee range of motion (ROM) was measured, the Brief Pain Inventory-short form and Oxford Knee Score questionnaires were used to collect data on patient-reported pain and function, and the 15-dimensional health-related questionnaire was used to assess quality of life preoperatively and 3 and 12 months postoperatively. The patients reported satisfaction to TKA 3 and 12 months postoperatively. Data concerning infectious and thromboembolic events within 90 postoperative days and revision surgery, manipulation under anesthesia, and mortality within 1 year were collected. A separate post hoc analysis was performed for 399 participants to assess the effects of BMI on the respective outcomes.

RESULTS

A 1-unit increase in BFP affected the ROM by -0.37° (95% confidence interval (CI) = -0.60 to -0.13) 12 months after surgery. BFP was not significantly associated with the operation time or adverse events. However, the number of most adverse events remained too low for adjusted analysis. A 1-unit increase in BMI increased the operation time by 0.57 min (95% CI = 0.10 to 1.04) and affected the ROM by -0.47° (95% CI = -0.74 to -0.20) 12 months postoperatively. Neither BFP nor BMI was significantly associated with acute pain, pain management, length of stay, or with pain, function, quality of life, or satisfaction to TKA at 12 months after surgery.

CONCLUSIONS

BFP seems to be a poor predictor of in-hospital results and of patient-reported outcomes 1 year after TKA.

TWITTER HANDLE

In this secondary analysis of a randomized trial, body fat percentage was poorly predictive of clinical outcomes during hospital stay and of patient-reported outcomes 1 year after TKA.

Postoperative pain as a risk factor for stiff knee following total knee arthroplasty and excellent patientreported outcomes after manipulation under anesthesia

BACKGROUND AND PURPOSE

Manipulation under anesthesia (MUA) is the first-choice treatment for stiffness following total knee arthroplasty (TKA) unresponsive to pain management and physiotherapy. Some of the predisposing factors and patient-reported outcome measures (PROMs) following MUA remain poorly studied. We retrospectively investigated the etiological risk factors and the outcomes of MUA.

PATIENTS AND METHODS

391 TKA patients from a randomized trial comparing the use of a tourniquet and anesthesia (spinal or general) were analyzed, and patients needing MUA were identified (MUA group). We evaluated in-hospital opioid consumption, Oxford Knee Score (OKS), range of motion (ROM), and pain assessed by the Brief Pain Inventory-short form with a 1-year follow-up.

RESULTS

39 (10%) MUA patients were identified. The MUA patients were younger (60 years vs. 64 years, difference -4, 95% CI -6 to -1) and had higher postoperative oxycodone consumption (66 mg vs. 51 mg, median difference 11, CI 1-22) than the no-MUA patients. The proportion of MUA patients who contacted the emergency department within 3 months because of pain was larger than that of non-MUA patients (41% vs. 12%, OR 5, CI 3-10). At the 1-year follow-up, the ROM was improved by 39° following MUA, but the total ROM was worse in the MUA group (115° vs. 124°, p < 0.001). No difference was found in the OKS between the MUA and no-MUA patients.

INTERPRETATION

Higher postoperative pain seems to predict MUA risk. MUA performed 3 months postoperatively offers substantial ROM improvement and comparable PROMs to no-MUA patients 1 year after TKA.

Use of a Tourniquet and Spinal Anesthesia Increases Satisfactory Outcomes After Total Knee Arthroplasty: A Randomized Study

BACKGROUND

Total knee arthroplasty (TKA) is usually performed successfully with or without a tourniquet and under spinal anesthesia (SA) or general anesthesia (GA). However, 10% to 34% of patients experience dissatisfaction and pain after TKA. We aimed to compare the effects of tourniquet use and SA or GA on TKA outcomes.

METHODS

We randomly assigned 404 patients to 4 study groups: SA without a tourniquet (NT/SA), SA with a tourniquet (T/SA), GA without a tourniquet (NT/GA), and GA with a tourniquet (T/GA). The primary outcome was the change in the Oxford Knee Score (OKS) at 1 year postoperatively. Secondary outcomes included a satisfactory TKA outcome assessed using the OKS minimal important change (MIC) and OKS patient acceptable symptom state (PASS), adverse events, and quality of life using the 15-dimensional health-related quality of life tool.

RESULTS

At 1 year, the OKS was obtained for 381 patients. In the 2-group comparisons, the tourniquet did not affect the OKS improvement. The SA group had more substantial improvement in the OKS than the GA group (16.21 compared with 14.08 a mean difference of 2.13; 95% confidence interval [CI], 0.55 to 3.71; p = 0.008). In the 4-group comparisons, the T/SA group had more substantial improvements in the OKS than the NT/GA group (16.87 compared with 13.65, a mean difference of 3.2; 95% CI, 0.28 to 6.17; p = 0.026). The SA group reached the OKS MIC more frequently than the GA group (91.7% compared with 81.7%; odds ratio [OR] = 2.49 [95% CI, 1.32 to 4.69]; p = 0.005). The SA group also reached the OKS PASS more frequently than the GA group (86.0% compared with 75.7%; OR = 2.00 [95% CI, 1.18 to 3.39]; p = 0.010). The T/SA group had significantly more patients reaching the OKS MIC than the NT/GA group (95.7% compared with 79.6%; p = 0.005) and more patients reaching the OKS PASS than the NT/GA group (92.6% compared with 74.5%; p = 0.004). No differences were seen with respect to adverse events in any comparisons.

CONCLUSIONS

The tourniquet had no detrimental effects on the outcomes of TKA. SA had a positive effect on the OKS. The use of SA combined with a tourniquet resulted in the best improvement in OKS and the highest proportion of satisfactory outcomes with TKA.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Anesthesia Method, Tourniquet Use, and Persistent Postsurgical Pain after Total Knee Arthroplasty: A Prespecified Secondary Analysis of a Randomized Trial

BACKGROUND

Persistent postsurgical pain after total knee arthroplasty is a common problem and a major reason for patient dissatisfaction. This secondary analysis aimed to investigate the effects of anesthesia (spinal vs. general) and tourniquet use on persistent pain after total knee arthroplasty.

METHODS

In this secondary analysis of a previously presented parallel, single-center, randomized trial, 404 patients scheduled for total knee arthroplasty were randomized to spinal versus general anesthesia and no-tourniquet versus tourniquet groups. Patients assessed pain using the Brief Pain Inventory-short form preoperatively and 3 and 12 months postoperatively. The prespecified main outcome was the change in "average pain" measured with numerical 0 to 10 rating scale 1 yr postoperatively. The threshold for clinical importance between groups was set to 1.0.

RESULTS

The change in average pain scores 1 yr postoperatively did not differ between the spinal and general anesthesia groups (-2.6 [SD 2.5] vs. -2.3 [SD 2.5], respectively; mean difference, -0.4; 95% CI, -0.9 to 0.1; P = 0.150). The no-tourniquet group reported a smaller decrease in the average pain scores than the tourniquet group (-2.1 [SD 2.7] vs. -2.8 [SD 2.3]; mean difference, 0.6; 95% CI, 0.1 to 1.1; P = 0.012). After 1 yr, the scores concerning the mean of four pain severity variables (numerical rating scale) decreased more in the spinal than in the general anesthesia group (-2.3 [SD 2.2] vs. -1.8 [SD 2.1]; mean difference, -0.5; 95% CI, -0.9 to -0.05; P = 0.029) and less in the no-tourniquet than in the tourniquet group (-1.7 [SD 2.3] vs. -2.3 [SD 2.0]; mean difference, 0.6; 95% CI, 0.2 to 1.0; P = 0.005). None of the differences in pain scores reached the threshold for clinical importance.

CONCLUSIONS

The type of anesthesia (spinal vs. general) or tourniquet use has no clinically important effect on persistent postsurgical pain after total knee arthroplasty.

EDITOR’S PERSPECTIVE

Intravenous patient-controlled analgesia vs nurse administered oral oxycodone after total knee arthroplasty: a retrospective cohort study

OBJECTIVES

Severe post-operative pain is common after total knee arthroplasty. Patient-controlled analgesia is an alternative method of pain management, whereby a patient administers his or her own pain medication. Patients seem to prefer this method over nurse-administered analgesia. However, it remains unclear whether patients using patient-controlled analgesia devices use higher or lower doses of opioids compared to patients treated with oral opioids.

METHODS

This retrospective study examined 164 patients undergoing total knee arthroplasty. Post-operatively, 82 patients received oxycodone via intravenous patient-controlled analgesia devices, while the pain medication for 82 patients in the control group was administered by nurses. The main outcome measure was the consumption of intravenous opioid equivalents within 24 h after surgery. Secondary outcome measures were the use of anti-emetic drugs and the length of stay. Furthermore, we evaluated opioid-related adverse event reports.

RESULTS

The consumption of opioids during the first 24 h after surgery and the use of anti-emetic drugs were similar in both groups. The median opioid dose of intravenous morphine equivalents was 41.1 mg (interquartile range (IQR): 29.5-69.1 mg) in the patient-controlled analgesia group and 40.5 mg (IQR: 32.4-48.6 mg) in the control group, respectively. The median length of stay was 2 days (IQR: 2-3 days) in the patient-controlled analgesia group and 3 days (IQR: 2-3 days) in the control group (p=0.02). The use of anti-emetic drugs was similar in both groups.

CONCLUSIONS

The administration of oxycodone via intravenous patient-controlled analgesia devices does not lead to increased opioid or anti-emetic consumptions compared to nurse-administered pain medication after total knee arthroplasty. Patient-controlled analgesia might lead to shortened length of stay.

Does Regional Anesthesia Reduce Complications Following Total Hip and Knee Replacement Compared With General Anesthesia? An Analysis From the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BACKGROUND

Regional anesthesia is increasingly used in enhanced recovery programs following total hip replacement (THR) and total knee replacement (TKR). However, debate remains about its potential benefit over general anesthesia given that complications following surgery are rare. We assessed the risk of complications in THR and TKR patients receiving regional anesthesia compared with general anesthesia using the world's largest joint replacement registry.

METHODS

We studied the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man linked to English hospital inpatient episodes for 779,491 patients undergoing THR and TKR. Patients received either regional anesthesia (n = 544,620, 70%) or general anesthesia (n = 234,871, 30%). Outcomes assessed at 90 days included length of stay, readmissions, and complications. Regression models were adjusted for patient and surgical factors to determine the effect of anesthesia on outcomes.

RESULTS

Length of stay was reduced with regional anesthesia compared with general anesthesia (THR = -0.49 days, 95% confidence interval [CI] = -0.51 to -0.47 days, P < .001; TKR = -0.47 days, CI = -0.49 to -0.45 days, P < .001). Regional anesthesia also had a reduced risk of readmission (THR odds ratio [OR] = 0.93, CI = 0.90-0.96; TKA OR = 0.91, CI = 0.89-0.93), any complication (THR OR = 0.88, CI = 0.85-0.91; TKA OR = 0.90, CI = 0.87-0.93), urinary tract infection (THR OR = 0.85, CI = 0.77-0.94; TKR OR = 0.87, CI = 0.79-0.96), and surgical site infection (THR OR = 0.87, CI = 0.80-0.95; TKR OR = 0.84, CI = 0.78-0.89). Anesthesia type did not affect the risk of revision surgery or mortality.

CONCLUSION

Regional anesthesia was associated with reduced length of stay, readmissions, and complications following THR and TKR when compared with general anesthesia. We recommend regional anesthesia should be considered the reference standard for patients undergoing THR and TKR.

Postoperative Pain Management in Total Knee Arthroplasty

Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end‐stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and retention of urine, which limit their application in daily clinical practice. The aim of this review was to discuss the current postoperative pain management regimens for TKA. Our review of the literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, peripheral nerve blockade, patient‐controlled analgesia and local infiltration analgesia, and oral opioid/nonopioid medications. Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA.

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

BACKGROUND AND PURPOSE

Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research.

METHODS AND MATERIALS

We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital.

RESULTS

Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction.

CONCLUSION

The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.