Open-Label Randomized Clinical Trial to Assess the Effects of Preoperative Acupuncture in High Anxiety Patients Undergoing Total Knee or Hip Arthroplasty.

Background: Preoperative state anxiety is a known predisposing factor for enhanced postoperative pain and hindered recovery following total knee or hip replacement. Acupuncture administered preoperatively has been associated with reduced anxiety in surgical studies, yet evidence of its efficacy in the orthopedic surgical setting is limited. Objective: This study investigated the effects of preoperative acupuncture on preoperative anxiety and pain and compared acute postoperative pain between acupuncture and control patient groups. Design: Parallel-arm, open-label, randomized controlled trial. Setting: Bone and Joint Institute, Hartford Hospital, Hartford, CT. Participants: Sixty middle-aged and elderly men and women with clinically validated preoperative anxiety undergoing elective total hip or knee replacement. Intervention: One-to-one randomization to preoperative acupuncture (n = 30) or no acupuncture treatment (n = 30) on the day of surgery. Coprimary outcomes: Anxiety before and after preoperative acupuncture using the visual analog scale and postsurgical pain using the numeric pain scale. Secondary outcomes: Incidence of acupuncture-related complications, pain before and after acupuncture, nausea and vomiting incidence, opioid consumption, anxiolytics and antiemetics use, and patient satisfaction. Results: Patients reported lower anxiety and pain preoperatively following acupuncture compared with before treatment (both p < 0.001). Postoperatively, the acupuncture group reported lower pain in the first 3 h than the control group, although this difference was not statistically significant. No significant differences in postoperative complications or patient satisfaction were observed between the study groups. Most patients were satisfied with the acupuncture treatment and reported a likelihood of considering preoperative acupuncture for future surgeries. Conclusions: These preliminary findings support that preoperative acupuncture is a safe and effective means to reduce perioperative anxiety and pain in patients undergoing total hip or knee replacement surgery. Additional studies should be conducted to best determine the value of preoperative acupuncture in total hip or knee patients presenting with surgically related anxiety. Clinical Trial Registration: ClinicalTrials.gov (10/31/2023, NCT06099223).

The Role of Imageless Computer-Assisted Navigation During Total Knee Arthroplasty on Femoral Component Sagittal Alignment and Outcomes.

Background: While total knee arthroplasty (TKA) is highly successful, 15%-20% of patients are not satisfied postoperatively, which may be due to alignment of the TKA components. Imageless computer navigation was developed to increase implant alignment accuracy and precision, but controversy surrounds the patient benefit of this technology. The target of femoral sagittal alignment and its role in patient-reported outcomes (PROMs) after TKA using assistive technology has not been well-defined. Methods: Femoral sagittal alignment, 30-day complications, and PROMs through 1 year were collected retrospectively from unilateral elective TKA patients who underwent surgery between July 2020 and February 2023. Two surgeons equally versed in conventional and imageless navigation techniques participated in patient record identification. Students t-tests and chi-square tests of proportion were used to compare outcomes, 30-day complications, and alignment. Results: Completed PROMs were available for 387 patients; 181 in the computer navigation group and 206 in the conventional arthroplasty group. PROMs were statistically significantly different between groups, favoring computer navigation (P = .014 at 12 months). Lateral femoral angle measurements were greater in females who underwent TKA with computer navigation (P < .001). Of note, 14 patients in the conventional technique group returned to the emergency department within 30 days, as compared to 4 in the navigation group (P = .033). Conclusions: PROMs are improved in the navigation group compared to the conventional technique group. Fewer patients in the navigation group returned to the emergency department. Navigation appeared to provide a small benefit compared to conventional techniques, though final lateral femoral angle was not predictive of outcomes. Additional surgical characteristics may need to be examined to determine the reasons for the differences in outcomes between these techniques.

Increasing Body Mass Index Not Associated With Worse Patient-Reported Outcomes After Primary THA or TKA.

INTRODUCTION: As the US obesity epidemic continues to grow, so too does comorbid hip and knee arthritis. Strict body mass index (BMI) cutoffs for total hip and knee arthroplasty (THA and TKA) in the morbidly obese have been proposed and remain controversial, although current American Academy of Orthopaedic Surgeons guidelines recommend a BMI of less than 40 m/kg2 before surgery. This study sought to compare patient-reported outcomes and 30-day complication, readmission, and revision surgery rates after THA or TKA between morbidly obese patients and nonmorbidly obese control subjects. METHODS: All patients undergoing primary THA and TKA at our institution from May 2020 to July 2022 were identified. Patient demographics, surgical time, length of stay and 30-day readmission, revision surgery, and complication rates were prospectively collected. Preoperative and postoperative Hip and Knee Society (Hip Osteoarthritis Outcome Score [HOOS] and Knee Osteoarthritis Outcome Score [KOOS]) were collected. Patients were stratified by BMI as ideal weight (20 to 24.9), overweight (25 to 29.9), class I obese (30 to 34.9), class II obese (35 to 39.9), and morbidly obese (>40 m/kg2). RESULTS: A total of 1,423 patients were included for final analysis. No difference was observed in 30-day unplanned return to emergency department, readmission, or revision surgery in the morbidly obese cohort. Morbidly obese patients undergoing THA had lower preoperative HOOS (49.5 versus 54.5, P = 0.004); however, there was no difference in postoperative HOOS or KOOS at 12 months across all cohorts. DISCUSSION: No difference was observed in 30-day return to emergency department, readmission, or revision surgery in the morbidly obese cohort. Despite a lower preoperative HOOS, there was no difference in 12-month HOOS or KOOS when stratified by BMI. These findings suggest that such patients may achieve similar benefit from arthroplasty as their ideal weight counterparts.

Liposomal bupivacaine provides superior pain control compared to bupivacaine with adjuvants in interscalene block for total shoulder replacement: a prospective double-blinded, randomized controlled trial.

INTRODUCTION: Optimal pain control methods after total shoulder arthroplasty (TSA) achieve reduced opioid consumption, shortened hospital stay, and improved patient satisfaction in addition to adequate analgesia. Interscalene brachial plexus block is the gold standard for TSA, yet it typically does not provide pain relief lasting beyond 24 hours. Liposomal bupivacaine (LB) purportedly provides prolonged analgesia, yet it has been minimally explored for interscalene block, and it is significantly more expensive than standard bupivacaine. METHODS: This is a prospective, 2-arm, double-blinded randomized controlled trial. Subjects presenting for anatomic or reverse TSA were randomized in a 1:1 ratio to receive interscalene brachial plexus block with either LB plus bupivacaine (LBB group) or bupivacaine plus dexamethasone and epinephrine (BDE group). The primary outcome was 120-hour postoperative opioid consumption. Secondary outcomes were pain scores up to 96 hours postoperatively, pain control satisfaction, complications, level of distress from block numbness, and hospital stay. RESULTS: Ninety patients, 45 per group, were included in the intention-to-treat analysis and randomized. Because of withdrawal of consent and loss to follow-up, 40 in each group completed enrollment through postoperative day 60. Total 120-hour postoperative opioid consumption was similar between groups (P = .127), with no differences within 24- or 48-hour time intervals. Postoperative pain scores at 24-48 hours, 48-72 hours, 72-96 hours, and day 60 were significantly lower for the LBB group. DISCUSSION: LB interscalene brachial plexus block before total shoulder arthroplasty did not reduce 120-hour postoperative opioid consumption but significantly reduced postoperative pain between 24 and 96 hours and at postoperative day 60.

Salvage of distal tibia metaphyseal nonunions with the 90 degrees cannulated blade plate.

Nonunion of distal tibia metaphyseal fractures after trauma is a major problem. Treating these nonunions is made more challenging by the presence of symptomatic ipsilateral tibiotalar arthrosis. The current study examined the use of the 90 degrees cannulated blade plate as an alternative method of stable internal fixation for 13 distal tibia metaphyseal nonunions and simultaneous fusion of three arthritic tibiotalar joints in 13 patients (seven males and six females) with an average age of 42.4 years (range, 21-73 years). Each patient had an average of three prior procedures (range, 2-6). Patients were followed up for an average of 34.2 months (range, 24-55 months). All 13 patients achieved radiographic and clinical union an average of 15.6 weeks (range, 12-20 weeks) from the date of the definitive procedure. There were two broken screws, but no secondary procedures were required to obtain fusion. All patients were ambulatory without support at the last followup. The implant proved effective for stable internal fixation of distal tibia metaphyseal nonunions alone or with simultaneous fusion of the tibiotalar joint.