Lithium prevents glucocorticoid-induced osteonecrosis of the femoral head by regulating autophagy.

Autophagy may play an important role in the occurrence and development of glucocorticoid-induced osteonecrosis of the femoral head (GC-ONFH). Lithium is a classical autophagy regulator, and lithium can also activate osteogenic pathways, making it a highly promising therapeutic agent for GC-ONFH. We aimed to evaluate the potential therapeutic effect of lithium on GC-ONFH. For in vitro experiments, primary osteoblasts of rats were used for investigating the underlying mechanism of lithium's protective effect on GC-induced autophagy levels and osteogenic activity dysfunction. For in vivo experiments, a rat model of GC-ONFH was used for evaluating the therapeutic effect of oral lithium on GC-ONFH and underlying mechanism. Findings demonstrated that GC over-activated the autophagy of osteoblasts and reduced their osteogenic activity. Lithium reduced the over-activated autophagy of GC-treated osteoblasts through PI3K/AKT/mTOR signalling pathway and increased their osteogenic activity. Oral lithium reduced the osteonecrosis rates in a rat model of GC-ONFH, and restrained the increased expression of autophagy related proteins in bone tissues through PI3K/AKT/mTOR signalling pathway. In conclusion, lithium can restrain over-activated autophagy by activating PI3K/AKT/mTOR signalling pathway and up-regulate the expression of genes for bone formation both in GC induced osteoblasts and in a rat model of GC-ONFH. Lithium may be a promising therapeutic agent for GC-ONFH. However, the role of autophagy in the pathogenesis of GC-ONFH remains controversial. Studies are still needed to further explore the role of autophagy in the pathogenesis of GC-ONFH, and the efficacy of lithium in the treatment of GC-ONFH and its underlying mechanisms.

Connexin43 overexpression promotes bone regeneration by osteogenesis and angiogenesis in rat glucocorticoid-induced osteonecrosis of the femoral head.

Glucocorticoids induced osteonecrosis of the femoral head (GIONFH) is a devastating orthopedic disease. Previous studies suggested that connexin43 is involved in the process of osteogenesis and angiogenesis. However, the role of Cx43 potentiates in the osteogenesis and angiogenesis of bone marrow-derived stromal stem cells (BMSCs) in GIONFH is still not investigated. In this study, BMSCs were isolated and transfected with green fluorescent protein or the fusion gene encoding GFP and Cx43. The osteogenic differentiation of BMSCs were detected after transfected with Cx43. In addition, the migration abilities and angiogenesis of human umbilical vein endothelial cells (HUVECs) were been detected after induced by transfected BMSCs supernatants in vitro. Finally, we established GC-ONFH rat model, then, a certain amount of transfected or controlled BMSCs were injected into the tibia of the rats. Immunohistological staining and micro-CT scanning results showed that the transplanted experiment group had significantly promoted more bone regeneration and vessel volume when compared with the effects of the negative or control groups. This study demonstrated for the first time that the Cx43 overexpression in BMSCs could promote bone regeneration as seen in the osteogenesis and angiogenesis process, suggesting that Cx43 may serve as a therapeutic gene target for GIONFH treatment.

Effects of a Modified Long-Acting Cocktail on Analgesia and Enhanced Recovery After Total Hip Arthroplasty: A Double-Blinded Randomized Clinical Trial.

BACKGROUND: We compared the efficacy and safety of a modified cocktail for postoperative analgesia and early functional rehabilitation in patients undergoing total hip arthroplasty (THA). METHODS: Magnesium sulfate and sodium bicarbonate were added to a cocktail of ropivacaine, epinephrine, and dexamethasone. Primary outcome measures were visual analog scale (VAS) pain scores at various intervals after surgery, morphine consumption for rescue analgesia after surgery, and time to first rescue analgesia. Secondary outcomes were hip function after surgery, daily walking distance, quadriceps muscle strength, and the incidence of postoperative adverse reactions. RESULTS: Morphine consumption was significantly lower in the modified cocktail group than in the control group in the first 24 hours after surgery (6.2 ± 6.0 versus 14.2 ± 6.4 mg, P < .001), as was total morphine consumption (10.0 ± 8.6 versus 19.2 ± 10.1 mg, P < .001). The duration of the first rescue analgesia was significantly prolonged (23.7 ± 10.3 versus 11.9 ± 5.8 mg, P < .001). Morphine consumption was also reduced in the magnesium sulfate and sodium bicarbonate groups over a 24-hour period compared to the control group (P < .001). The modified cocktail group had significantly lower resting VAS pain scores than the control group within 24 hours after surgery (P < .050). The VAS pain scores during movement within 12 hours after surgery were also lower (P < .050). The experimental groups showed better hip range of motion (P < .050) and longer walking distance (P < .050) on the first postoperative day, and levels of inflammatory markers were significantly reduced. The incidence of postoperative adverse reactions was similar among the 4 groups. CONCLUSIONS: The modified cocktail with a new adjuvant can prolong the duration of postoperative analgesia, reduce the dosage of rescue analgesics, and accelerate early postoperative functional recovery in patients undergoing THA.

Efficacy of Oral Nefopam on Multimodal Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial.

BACKGROUND: Multimodal analgesia is central to pain management after total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding oral nefopam to multimodal analgesia for post-TKA pain management. METHODS: In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to either the nefopam or the control group. After surgery, patients in the nefopam group received 200 mg of celecoxib, 150 mg of pregabalin, and 40 mg of nefopam twice daily to control postoperative pain. Patients in the control group received 200 mg of celecoxib, 150 mg of pregabalin, and a placebo. Oxycodone hydrochloride (10 mg) was used as the rescue analgesic. If the pain remained poorly controlled, 10 mg of morphine hydrochloride was injected subcutaneously as a secondary rescue analgesic. The primary outcome was the postoperative consumption of oxycodone and morphine as rescue analgesics. Secondary outcomes were postoperative pain assessed using the visual analogue scale (VAS), functional recovery assessed by the range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates. RESULTS: Patients in the nefopam group had significantly lower postoperative oxycodone and morphine consumption within 24 hours after surgery and during hospitalization, lower VAS pain scores at rest and during motion within 24 h after surgery, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. However, the absolute reduction in 0 to 24 h opioid consumption, VAS pain scores, and knee range of motion did not exceed the reported minimal clinically important difference. Both groups had similar indicators of liver function and complication rates. CONCLUSIONS: Adding oral nefopam to multimodal analgesia resulted in statistically significant improvements in opioid consumption, VAS pain scores, and functional recovery. However, the amount of improvement may not be clinically important.

Influencing factors of hidden blood loss after primary total hip arthroplasty through the posterior approach: a retrospective study.

BACKGROUND: Total hip arthroplasty (THA) is an excellent treatment for the end-stage hip disease, and perioperative blood management strategies have been effectively applied to this procedure. However, many patients still experience anemia after the operation, which is usually overlooked by orthopedic surgeons due to the hidden blood loss (HBL) in the perioperative period. Therefore, the objective of this study was to evaluate HBL in patients undergoing primary THA using the posterior approach and to explore its influencing factors. METHODS: A retrospective analysis of 707 patients who underwent primary THA through the posterior approach was conducted in our hospital from January 2020 to January 2022. By applying Gross's and Nadler's formula, the HBL was calculated. Six quantitative variables (age, body mass index, surgical duration, albumin loss, preoperative hemoglobin, and hemoglobin loss) as well as four qualitative variables (gender, American Society of Anesthesiologists class, major preoperative diagnosis, and hypertension) of patients were analyzed using multivariate linear regression. RESULTS: The HBL was recorded at 700.39 ± 368.59 mL. As a result of multivariate linear regression analysis, it was determined that body mass index, surgical duration, and hemoglobin loss were all significant risk factors for HBL, whereas preoperative hemoglobin was considered a protective factor. It has been demonstrated that HBL is not significantly correlated with age, albumin loss, gender, ASA class, or major preoperative diagnosis, but it also did not differ from HBL by hypertension. CONCLUSIONS: Hidden blood Loss (HBL) in patients after primary total hip arthroplasty (THA) using the posterior approach is large and significant. When optimizing the perioperative management of THA, orthopedic surgeons should keep in mind HBL and its influencing factors, especially for patients with high body mass indexes, long surgical durations, and low preoperative hemoglobin levels. TRIAL REGISTRATION: This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100053888) in 02/12/2021, http://www.chictr.org.cn .

Efficacy of Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined With Local Infiltration Analgesia on Postoperative Pain After Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial.

BACKGROUND: This study examined whether pericapsular nerve group (PENG) block combined with local infiltration analgesia (LIA) could improve pain management and functional recovery after total hip arthroplasty. METHODS: All patients were randomly assigned to receive PENG block combined with LIA (PENG group) or sham PENG block and LIA (Sham group). The primary outcome was cumulative morphine consumption within 24 hours after surgery. Secondary outcomes were pain scores on a visual analog scale (VAS); time to first rescue analgesia; cumulative morphine consumption during hospitalization; intraoperative consumption of opioids; postoperative recovery; and postoperative complications. RESULTS: PENG patients consumed significantly less morphine within the first 24 hours and throughout hospitalization and smaller amounts of intraoperative opioids. There were significantly lower pain scores at rest and during motion within 24 hours in PENG patients. PENG patients took significantly longer until the first rescue analgesia and showed significantly better postoperative rehabilitation. However, the absolute change in morphine consumption and VAS scores did not exceed the reported minimal clinically important differences (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement). The two groups showed no difference in quadriceps muscle strength and postoperative complications. CONCLUSION: PENG block combined with LIA could improve postoperative pain relief, reduce opioid use, and enhance recovery in total hip arthroplasty patients, without weakening the quadriceps muscle strength. This work justifies further trials to examine the safety and efficacy of this block and to explore maximal effective volume of local anesthetic for motor-sparing PENG block.

Efficacy of Opioids in Preemptive Multimodal Analgesia for Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial.

BACKGROUND: Preemptive multimodal analgesia is a commonly used technique to control pain following total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of pre-emptive opioids for pain management in patients who underwent TKA. METHODS: In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to the oxycodone or control group. At 2 hours before surgery, patients in the oxycodone group received 400 mg celecoxib, 150 mg pregabalin, and 10 mg extended-release oxycodone hydrochloride. Patients in the control group received 400 mg celecoxib, 150 mg pregabalin, and placebo. The primary outcome was postoperative consumption of morphine hydrochloride as rescue analgesia. Secondary outcomes were time to first rescue analgesia, postoperative pain assessed by the visual analogue scale, functional recovery assessed by range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates. RESULTS: The 2 groups were similar in mean postoperative 0 to 24 hour morphine consumption (11.4 mg for control versus 12.4 mg for oxycodone group, P = .419) and mean total morphine consumption (18.2 versus 19.8 mg, P = .227). There were no statistical differences in secondary outcomes. CONCLUSIONS: In our study, preemptive opioid administration did not provide clinical benefits over placebo. Orthopaedic surgeons should consider not using pre-operative opioids in patients undergoing TKA.

Does living at high altitude increase the risk of bleeding events after total knee arthroplasty? A retrospective cohort study.

OBJECTIVE: Post-operative bleeding after total knee arthroplasty (TKA) is a frequent cause of post-operative complications. This study compared blood loss and indicators of coagulation and fibrinolysis between TKA patients living at low or high altitudes. METHODS: We retrospectively analyzed 120 patients at our institution who underwent primary TKA from May 2019 to March 2020, and we divided them into those living in areas about 500 m or > 3000 m above sea level. We compared the primary outcome of total blood loss between them. We also compared them in terms of several secondary outcomes: coagulation and fibrinolysis parameters, platelet count, reduction in hemoglobin, hidden blood loss, intra-operative blood loss, transfusion rate, and incidence of thromboembolic events and other complications. RESULTS: Total blood loss was significantly higher in the high-altitude group than in the low-altitude group (mean, 748.2 mL [95% CI, 658.5-837.9] vs 556.6 mL [95% CI, 496.0-617.1]; p = 0.001). The high-altitude group also showed significantly longer activated partial thromboplastin time, prothrombin time, and thrombin time before surgery and on post-operative day one, as well as increased levels of fibrinogen/fibrin degradation product on post-operative days one and three. Ecchymosis was significantly more frequent in the high-altitude group (41.7 vs 21.7%; relative risk (RR) = 1.923 [95% CI, 1.091-3.389]; p = 0.019). The two groups showed similar transfusion rates, and none of the patients experienced venous thromboembolism, pulmonary embolism, or infection. CONCLUSION: High altitude may alter coagulation and fibrinolysis parameters in a way that increases risk of blood loss after TKA. Such patients may benefit from special management to avoid bleeding events.

Comparison Between Ultrasound-Guided Suprainguinal Fascia Iliaca Block and Anterior Quadratus Lumborum Block for Total Hip Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Trial.

BACKGROUND: Nerve block is a key technique in postoperative analgesia for total hip arthroplasty (THA). This study aimed to compare ultrasound-guided suprainguinal fascia iliaca block (SFIB) and anterior quadratus lumborum block (AQLB) in patients undergoing primary THA. METHODS: In this prospective, double-blind, randomized controlled trial, 100 patients undergoing primary THA under general anesthesia were randomly allocated to receive an ultrasound-guided SFIB + sham AQLB (SFIB group), or an ultrasound-guided AQLB + sham SFIB (AQLB group). Before wound suture, all patients received periarticular infiltration analgesia which the local anesthetic was injected into joint capsule, exposed gluteal and abductor muscles, peritrochanteric zone, and subcutaneous tissue under the incision as multiple sites. The primary outcome was postoperative morphine consumption within 24 hours after surgery. Secondary outcomes were the time to first rescue analgesia, postoperative pain assessed on the visual analog scale, postoperative quadriceps strength, the time to hospital discharge, and the incidence of postoperative complications. RESULTS: There were no significant differences between the 2 groups concerning morphine consumption within 24 hours after surgery (P = .774), the time to first rescue analgesia (P = .890), the time to hospital discharge (P = .532), and the incidence of postoperative complications (P > .05). The visual analog scale pain scores at rest and during motion also were similar at all time points (P > .05). Significantly more patients in the SFIB group experienced quadriceps muscle weakness at 2 hours (P = .008) and 6 hours (P = .009) after surgery. CONCLUSION: Under the circumstances of this study, when combined with periarticular infiltration analgesia, the SFIB provided similar pain relief compared with AQLB in patients undergoing THA, but was associated with muscle weakness within 6 hours after surgery.

Porous tantalum shell and augment for acetabular defect reconstruction in revision total hip arthroplasty: a mid-term follow-up study.

AIM: The use of porous tantalum trabecular metal (TM) shell and augment to reconstruct acetabular defects in revision total hip arthroplasty (THA) is a reliable technique. We evaluated the mid-term implant survival, clinical, and radiological outcomes of our first 48 revisions using this technique. PATIENTS AND METHODS: A total of 45 patients (48 hips) who had acetabular revision of THA between 2011 and 2017 using TM shell and augment with possible mid-term follow-up were included. Twenty-two patients were men (49%) and 23 were women (51%), mean age was 62.5 years (34 to 85) and mean follow-up was 75 months (54 to 125). Twenty-four hips (50%) had a Paprosky IIIA defect, 14 (29.2%) had a type IIIB defect, six (12.5%) had a type IIC defect, and four hips (8.3%) had a type IIB defect. None of the patients had pelvic discontinuity (PD). RESULTS: At a mean 6.25 years follow-up, all hips remained well-fixed and implant survival of 100% with the need of re-revision as the end point. Screw fixation was used for all shells; augments and the shell-augment interface was cemented. Excellent pain relief (mean WOMAC score pain 90.5, (38.3 to 100)), and functional outcomes (mean WOMAC function 88.3 (31.9 to 100), mean OHS 89.2 (31.8 to 100)) were noted. Patient satisfaction scores were excellent. CONCLUSION: This study demonstrated satisfactory mid-term clinical and radiological outcomes of using TM shell and augment for reconstructing major acetabular defects without PD in revision THA.

Glucocorticoids decreased Cx43 expression in osteonecrosis of femoral head: The effect on proliferation and osteogenic differentiation of rat BMSCs.

Glucocorticoid (GC)-induced osteonecrosis of the femoral head (GC-ONFH) is considered as one of the most serious side effects of long-term or over-dose steroid therapy. However, the underlying cause mechanisms are still not fully investigated. We firstly established a rat model of GC-ONFH and injected lipopolysaccharide (LPS) and methylprednisolone (MPS). We found that the expressions of Cx43, Runx2, ALP and COLⅠ were more decreased than the normal group. Secondly, the isolated rat bone marrow stem cells (BMSCs) were treated with dexamethasone (Dex) in vitro, and the expressions of Cx43, Runx2, ALP and COLⅠ were decreased significantly. Moreover, the results of immunofluorescence staining, alizarin red staining, EdU assay and CCK8 showed that the osteogenic differentiation and the proliferation capacity of BMSCs were decreased after induced by Dex. A plasmid of lentivirus-mediated Cx43 (Lv-Cx43) gene overexpression was established to investigate the function of Cx43 in BMSCs under the Dex treatment. Findings demonstrated that the proliferation and osteogenic differentiation abilities were enhanced after Lv-Cx43 transfected to BMSCs, and these beneficial effects of Lv-Cx43 were significantly blocked when PD988059 (an inhibitor of ERK1/2) was used. In conclusion, the overexpression of Cx43 could promote the proliferation and osteogenic differentiation of BMSCs via activating the ERK1/2 signalling pathway, which provide a basic evidence for further study on the detailed function of Cx43 in GC-ONFH.

Adding corticosteroids to periarticular infiltration analgesia improves the short-term analgesic effects after total knee arthroplasty: a prospective, double-blind, randomized controlled trial.

PURPOSE: Periarticular infiltration analgesia (PIA) is widely used to control postoperative pain in patients who underwent total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding corticosteroids to the PIA cocktail for pain management in patients who underwent TKA. METHODS: The patients were randomized to the corticosteroid or control group (double-blind). The patients in the corticosteroid group received a periarticular infiltration of an analgesic cocktail of ropivacaine, epinephrine, and dexamethasone. Dexamethasone was omitted from the cocktail in the control group. The primary outcomes were postoperative pain [assessed using a visual analog scale (VAS)], time until the administration of first rescue analgesia, morphine consumption, and postoperative inflammatory biomarkers [C-reactive protein (CRP) and interleukin-6 (IL-6)]. The secondary outcomes were functional recovery, assessed by the range of knee motion, quadriceps strength, and daily ambulation distance. The tertiary outcomes included postoperative adverse effects. RESULTS: The patients in the corticosteroid group had significantly lower resting VAS scores at 6 and 12 h after surgery, lower VAS scores during motion up to 24 h after surgery, and lower levels of inflammatory biomarkers. All the differences in the VAS scores between the two groups did not reach the point to be considered clinically significant. The additional use of corticosteroid significantly prolonged analgesic effects and led to lower rescue morphine consumption. The patients in the corticosteroid group had significantly better functional recovery on the first day after surgery. The two groups had a similar occurrence of adverse effects. CONCLUSIONS: Adding corticosteroids to an analgesic cocktail for PIA could lightly improve early pain relief and accelerate recovery in the first 24 h after TKA. LEVEL OF EVIDENCE: Randomized controlled trial, Level I.

Comparison of Postoperative Outcomes Between Traditional Longitudinal Incision and Bikini Incision in Total Hip Arthroplasty via Direct Anterior Approach: A Randomized Controlled Trial.

BACKGROUND: The purpose of this study is to compare a traditional longitudinal incision to an oblique "bikini" incision during total hip arthroplasty (THA) via direct anterior approach (DAA), in terms of the aesthetic appearance of the scar, postoperative functional recovery, and complications. METHODS: This study is a single-surgeon experience in the Chinese population. Patients who came to our institute needing a THA via DAA were enrolled in our randomized controlled trial and randomly allocated to undergo traditional longitudinal incision (control) or bikini incision. Primary outcomes were measured using the scar cosmesis assessment and rating scale, the visual analog scale for pain, Oxford hip score, and University of California Los Angeles activity-level rating. Secondary outcomes were postoperative serum markers of muscle damage, inflammation, hemoglobin drop, and implant stability. The occurrence of postoperative complications, such as nerve and wound healing, was also recorded. RESULTS: There were no differences in demographic or clinical characteristics before surgery. A greater proportion of patients in the bikini group were satisfied with the appearance of their scar, giving significantly better scar cosmesis assessment and rating scores. There was no difference in postoperative functional recovery, levels of serum markers, or positioning of the implant components. Incision type had no effect on duration of hospitalization. The incidence of complications did not differ significantly between groups. CONCLUSION: The bikini incision can improve patients' subjective satisfaction with scar aesthetics after THA via DAA and does not detract from a quick functional recovery. Studies with larger sample sizes should be conducted to further investigate associated complications. THE CLINICAL TRIAL REGISTRATION NUMBER: ChiCTR1900022870.

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

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

Comparison of Intravenous and Topical Dexamethasone for Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Study of Effects on Dexamethasone Administration Route and Enhanced Recovery.

BACKGROUND: The optimal route for dexamethasone (DEX) administration regimen for patients undergoing primary TKA has not been investigated. This study aims to determine whether intravenous and topical DEX provide different clinical effects in patients with TKA. METHODS: In this double-blinded, placebo-controlled trial, 90 patients undergoing primary TKA were randomized to intravenous DEX group (n = 45) or topical DEX group (n = 45, DEX applied in anesthetic cocktail for periarticular injection). The primary outcome was postoperative VAS pain score and morphine consumption. Secondary outcomes were included knee swelling, knee flexion, and extension angle, Knee Society Score (KSS), and postoperative hospital stays. Tertiary outcomes assessed the blood-related metrics, including inflammatory biomarkers and fibrinolysis parameters. Finally, nausea and vomiting and other adverse events were compared. RESULTS: The topical administration of DEX provide lower pain score at 2h, 8h, 12h at rest (P < .05) and 12h, 24h with activity (P < .05), and less knee swelling in the first postoperative day (P < .05), while intravenous DEX was more effective in decreasing blood inflammatory biomarkers, including C-reactive protein (CRP) at postoperative 24h (P < .05) and interleukin-6 (IL-6) at postoperative 24h, 48h (P < .05), and reducing postoperative nausea (P < .05) for patients receiving TKA. However, there was no significant difference in knee flexion and extension angle, KSS, postoperative hospital stays, and complications occurrence (P > .05) between intravenous and topical DEX after TKA. CONCLUSION: Topical administration of DEX provided better clinical outcomes on postoperative pain management and knee swelling early after TKA, while intravenous DEX was more effective in decreasing blood inflammatory biomarkers and preventing postoperative nausea.

Ultrasound-guided adductor canal block combined with lateral femoral cutaneous nerve block for post-operative analgesia following total knee arthroplasty: a prospective, double-blind, randomized controlled study.

PURPOSE: The purpose of this study was to investigate whether adductor canal block (ACB) combined with lateral femoral cutaneous nerve block (LFCNB) could improve the efficacy of post-operative analgesia in a comparison with a standard peri-articular infiltration analgesia (PIA) after a total knee arthroplasty (TKA). METHODS: One hundred and sixty patients of scheduled unilateral primary TKA were randomly allocated into two groups for post-operative analgesia. Eighty cases were treated with ACB combined with LFCNB and the other eighty treated with PIA. The primary outcomes were pain visual analogue scale (VAS) and rescue pain killer consumption, and the secondary outcomes were knee active range of motion (ROM), quadriceps strength, patients' ambulation ability, Knee Society Score (KSS), length of hospital stay, and adverse events. RESULTS: We found that ACB combined with LFCNB was better on decreasing the post-operative pain score within 12 hours at rest and 8 h with activity (p < 0.05) and provided longer duration of analgesia (19.91 ± 5.09 VS 12.06 ± 3.67 h, p < 0.01) and less rescue morphine consumption (13.63 ± 9.84 vs 18.00 ± 11.52 mg, p = 0.011) than the PIA. There was no significant difference between the two groups (p > 0.05) in terms of knee ROM, quadriceps strength, daily mobilization distance, KSS, and complication occurrence. CONCLUSIONS: ACB combined with LFCNB provides a significantly better pain control, less opioid consumption, and longer duration of analgesia than peri-articular infiltration while preserving muscle function without affecting knee functional recovery nor the length of stay or side effects occurrence.

Meta-analysis of retrospective studies suggests that the pre-operative opioid use is associated with an increased risk of adverse outcomes in total hip and or knee arthroplasty.

BACKGROUND: Opioid use is prevalent in the general population. This systematic review and meta-analysis sought to evaluate whether it affects patient-reported outcomes (PROs) following total hip or knee arthroplasty. METHODS: The following databases were systematically searched on February 5, 2020: Medline, Embase (Ovid), Cochrane Library, and Web of Science. Studies were included if they compared patients who received opioids or not before total hip or knee arthroplasty. Outcomes of interest were rates of post-operative revision, peri-prosthetic infection, and readmission. RESULTS: Ten retrospective studies were included for review. Pre-operative opioid use was identified as a risk factor for post-operative revision [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.15-1.73, p<0.01], peri-prosthetic infection (OR 1.36, 95% CI 1.08-1.71, p=0.01), and readmission (OR 1.41, 95% CI 1.20-1.75, p<0.01). CONCLUSION: The available evidence indicates that pre-operative opioid use increases the risk of adverse outcomes following total hip or knee arthroplasty. Orthopedic physicians should consider these risks when treating their patients.

Femoral Head and Neck Fenestration Through a Direct Anterior Approach Combined With Compacted Autograft for the Treatment of Early Stage Nontraumatic Osteonecrosis of the Femoral Head: A Retrospective Study.

BACKGROUND: This study aimed to evaluate the effect of femoral head and neck fenestration combined with compacted autograft (light bulb procedure) through a direct anterior approach for early stage nontraumatic osteonecrosis of the femoral head. METHODS: We conducted a retrospective cohort study investigating 66 hips undergoing the light bulb procedure through the direct anterior approach (light bulb group) and 59 hips undergoing traditional core decompression (control group). Visual analog scale pain scores and range of hip motion were evaluated before discharge to assess the quality of functional recovery. Follow-up was conducted at 6 weeks, 3 months, 6 months, and annually after surgery until 4 years. The clinical effectiveness was evaluated by Harris hip score and the University of California Los Angeles activity-level score. Patients were followed up with postoperative X-ray and computed tomography. Survival was compared between the 2 groups by radiographic progression and receiving total hip arthroplasty. RESULTS: There was no significant difference in quality of functional recovery between the 2 groups. There were no significant differences in clinical outcomes within 1 year after surgery. Patients in the light bulb group had significantly better Harris hip scores and University of California Los Angeles activity-level scores from 2 years after surgery to the end of follow-up. During the 4-year follow-up, significantly fewer patients in light bulb group had radiographic progression (22.7% vs 44.1%) or received total hip arthroplasty (15.2% vs 30.5%). CONCLUSIONS: The light bulb procedure through a direct anterior approach offers significantly better results for the treatment of early stage nontraumatic osteonecrosis of the femoral head compared with traditional core decompression.

Efficacy of Adductor Canal Block Combined With Additional Analgesic Methods for Postoperative Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study.

BACKGROUND: The aim of this study is to evaluate the efficacy of adductor canal block (ACB) combined with additional analgesic methods in total knee arthroplasty (TKA) and investigate whether blocking the sensory nerves that are distributed in the posterior and lateral aspect of knee could improve postoperative pain control. METHODS: Two hundred scheduled patients for TKA were randomly allocated into 4 groups: Group A received ACB combined with iPACK (interspace between the popliteal artery and capsule of the knee) block and lateral femoral cutaneous nerve block (LFCNB); Group B received ACB combined with iPACK block; Group C received ACB combined with LFCNB; and Group D received ACB only. Postoperative pain score was the main primary outcome. Secondary outcomes included the morphine consumption and analgesic duration. Other outcomes included knee range of motion, quadriceps strength, ambulation, Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index physical function, timed up and go (TUG) test, and complications. RESULTS: Groups A, B, and C had lower postoperative pain scores within 12 hours at rest and 8 hours with activity than Group D (P < .05). In addition, Group A had lower morphine consumption than both Group C (P < .05) and Group D (P < .01). Group A had the longest analgesic duration (19.21 ± 3.22 hours) among all groups. There were no significant differences among the groups in terms of mobility and complication after surgery. CONCLUSION: Combining ACB with both iPACK and LFCNB is an effective method for decreasing early postoperative pain in TKA without increasing the complications or affecting the early rehabilitation.

Effects of morphine on peri-articular infiltration analgesia in total knee arthroplasty: a prospective, double-blind, randomized controlled trial.

PURPOSE: Peri-articular infiltration analgesia (PIA) is a widely used method to control post-operative pain in total knee arthroplasty (TKA) patients. However, there are limited data that support the use of morphine in PIA. This study aims to evaluate the efficacy of peri-articular morphine infiltration for pain management in TKA patients. METHODS: Based on a double-blind, randomized approach, patients were allocated to the morphine or control group. Patients in the morphine group received a peri-articular infiltration of an analgesic cocktail consisting of ropivacaine, epinephrine, and morphine. Morphine was omitted from the cocktail in the control group. Primary outcomes were post-operative consumption of morphine hydrochloride used for rescue analgesia and post-operative pain as assessed by visual analog scale (VAS) score. Secondary outcomes were functional recovery as assessed by a range of knee motion, quadriceps strength, and daily ambulation distance. The duration of hospital stay was also recorded. Tertiary outcomes included the occurrence of post-operative adverse effects and the consumption of antiemetics. RESULTS: Patients in the morphine group had significantly lower post-operative morphine consumption in the first 24 h and total morphine consumption. There was no significant difference between the two groups in post-operative VAS pain scores at rest or during motion. There was no significant difference between the two groups in the post-operative knee range of motion, quadriceps strength, daily ambulation distance, or duration of post-operative hospital stay. The two groups were similar in the incidence of adverse effects and the consumption of antiemetics. CONCLUSION: Adding morphine into the analgesic cocktail of PIA could reduce postoperative morphine consumption in TKA patients, but does not improve early pain relief or accelerate functional recovery or provide clinical benefits for TKA patients. In addition, the complications and safety of peri-articular morphine infiltration need to be further investigated in larger sample studies.