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BACKGROUND: Pain control and patient satisfaction after total knee arthroplasty (TKA) have room for improvement. While studies have reported better analgesic outcomes with antidepressants like duloxetine in patients who do not have central sensitivity (CS), we undertook this trial to determine the short and midterm analgesic role of low-dose duloxetine in patients who do not have CS. METHODS: This prospective, double-blinded, randomized, placebo-controlled trial was conducted in 106 patients undergoing single-setting, bilateral TKA under spinal anesthesia. There were 2 matched groups, with one given 20 mg of duloxetine and the other given a placebo (similar in appearance and weight) from preoperative day 2 to postoperative day 28. Follow-ups were scheduled at 48-hours, 1-week, 2-weeks, 4-weeks, and 3-months. Pain was measured using a visual analogue scale at rest and visual analogue scale at mobilization (mVAS). Secondary measures included additional non-steroidal anti-inflammatory drug consumption, patient satisfaction, and safety profile. RESULTS: The visual analogue scale at rest in the duloxetine group was better in the first 48 hours (6.38 ± 1.32 versus 7.02 ± 0.99; P = .017), 1-week (4.76 ± 1.24 versus 5.89 ± 1.06; P < .001), and 2-weeks (3.34 ± 1.19 versus 4.26 ± 1.02; P < .001) follow-up. The mVAS remained significantly higher in the duloxetine group in the first 48 hours (7.23 ± 1.12 versus 8.21 ± 0.69; P < .001), 1-week (5.83 ± 1.11 versus 6.82 ± 0.92; P < .001), and 2 weeks (3.70 ± 0.89 versus 4.60 ± 1.03; P < .001) follow-up. Both outcomes became comparable from 4-week follow-up onward. Patient satisfaction (8.44 ± 1.68 versus 7.17 ± 1.04; P < .001) and additional non-steroidal anti-inflammatory drug consumption (2,770 ± 533.05 versus 3,566.04 ± 464.54; P < .001) were better in the duloxetine group, with a comparable safety profile. CONCLUSIONS: In patients who did not have CS, persistent pain after bilateral TKA can be managed safely and successfully by a daily dose of 20 mg Duloxetine, improving patient satisfaction and analgesic consumption in the acute postoperative phase.
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Introduction: Common peroneal nerve palsy (CPNP) is a rare complication post total knee arthroplasty (TKA). Even though it is diagnosed acutely, the recovery potential is just over 50%. The average period for complete recovery in such cases is 5 months; however, the management remains controversial. Through this report, we present one such case of left sided complete CPNP after bilateral TKA who was conserved with various modalities. Even though the recovery was delayed, the patient made full recovery. Case Report: A 70-year-old female patient was diagnosed to have bilateral tricompartmental knee osteoarthritis with varus deformity, both clinically and radiologically (Kellgren-Lawrence grade 4). She underwent bilateral TKA in a single sitting as per the standard protocols practiced by the primary author. On post-operative day 1, she had left-sided foot drop with a complete sensory deficit. The patient underwent routine rehabilitation with an ankle foot orthosis splint in the immediate post-operative period, with simultaneous faradic current stimulation for the left lower limb. Periodic electromyography and nerve conduction study was done at the end of 4-week and 3-month post-TKA. At 6.5-month post-surgery, she made a full clinical recovery. Conclusion: The surgical maneuvers and full neurovascular examination before and after every TKA surgery should be carefully performed. Despite this, if a patient presents with CPNP, the surgeon need not take an aggressive approach, unlike fracture fixation cases. These patients can be managed conservatively using appropriate orthosis, physical therapy, and faradic current stimulation. Through this case, we attempt to report that CPNP patient can recover even after 6 months of surgery when there is no tangible cause for the palsy.
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Introduction: Lipomas are the most common benign mesenchymal tumor. The solitary subcutaneous lipoma accounts for approximately onequarter to one-half of all soft-tissue tumors. Giant lipomas involving the upper extremities are rare tumors. This case report presents a subcutaneous giant lipoma in the upper arm weighing 350 g. Due to its long-term presence, the lipoma caused discomfort and pressure effects in the arm. Gross underestimation on magnetic resonance imaging (MRI) made its removal challenging and difficult. Case Report: Through this case, we report a 64-year-old female who consulted us in the clinic with complaints of discomfort, feeling of heaviness, and a mass in the right arm since 5 years. On clinical examination, there was asymmetry in her arms with her right upper arm showing a visible swelling (8 cm × 6 cm) over its posterolateral aspect. On palpation, the mass was soft, boggy, not attached to the underlying bone or muscle, and not involving the skin. A provisional diagnosis of lipoma was made and the patient was asked to undergo plain and contrastenhanced MRI for the confirmation of the diagnosis, the extent of the lesion, and infiltration into the surrounding soft tissue. The MRI revealed a lobulated deep lipoma in the subcutaneous plane with pressure effects over the posterior fibers of the deltoid muscle. Surgical excision of the lipoma was carried out. The cavity was closed using retention stitches to prevent the formation of a seroma or hematoma. Complaints of pain, weakness, heaviness, and discomfort completely subsided by the 1st month follow-up. The patient was then followed up every 3 months for 1 year. No complication or recurrence was noted throughout this period of time. Conclusion: The extent of lipomas can be underestimated on radiological imaging. It is common to find a bigger lesion than reported and to plan and execute the incision and surgical approach accordingly. Blunt dissection should be preferred when there are chances of neurovascular involvement or injury.