Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial.

BACKGROUND: Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the use of oral TXA rather than intravenous (i.v.) TXA might improve safety and reduce cost, it is not clear whether oral administration is as effective. METHODS: This noninferiority trial randomly assigned consecutive patients undergoing primary THA or TKA under neuraxial anaesthesia to either one preoperative dose of oral TXA or one preoperative dose of i.v. TXA. The primary outcome was calculated blood loss on postoperative day 1. Secondary outcomes were transfusions and complications within 30 days of surgery. RESULTS: Four hundred participants were randomised (200 THA and 200 TKA). The final analysis included 196 THA patients (98 oral, 98 i.v.) and 191 TKA patients (93 oral, 98 i.v.). Oral TXA was non-inferior to i.v. TXA in terms of calculated blood loss for both THA (effect size=-18.2 ml; 95% confidence interval [CI], -113 to 76.3; P<0.001) and TKA (effect size=-79.7 ml; 95% CI, -178.9 to 19.6; P<0.001). One patient in the i.v. TXA group received a postoperative transfusion. Complication rates were similar between the two groups (5/191 [2.6%] oral vs 5/196 [2.6%] i.v.; P=1.00). CONCLUSIONS: Oral TXA can be administered in the preoperative setting before THA or TKA and performs similarly to i.v. TXA with respect to blood loss and transfusion rates. Switching from i.v. to oral TXA in this setting has the potential to improve patient safety and decrease costs.

No Difference in the Rate of Periprosthetic Joint Infection in Patients Undergoing the Posterolateral Compared to the Direct Anterior Approach.

BACKGROUND: There remains inconsistent data about the association of surgical approach and periprosthetic joint infection (PJI). We sought to evaluate the risk of reoperation for superficial infection and PJI after primary total hip arthroplasty (THA) in a multivariate model. METHODS: We reviewed 16,500 primary THAs, collecting data on surgical approach and all reoperations within 1 year for superficial infection (n = 36) or PJI (n = 70). Considering superficial infection and PJI separately, we used Kaplan-Meier survivorship to assess survival free from reoperation and a Cox Proportional Hazards multivariate models to assess risk factors for reoperation. RESULTS: Between direct anterior approach (DAA) (N = 3,351) and PLA (N = 13,149) cohorts, rates of superficial infection (0.4 versus 0.2%) and PJI (0.3 versus 0.5%) were low and survivorship free from reoperation for superficial infection (99.6 versus 99.8%) and PJI (99.4 versus 99.7%) were excellent at both 1 and 2 years. The risk of developing superficial infection increased with high body mass index (BMI) (hazard ratio [HR] = 1.1 per unit increase, P = .003), DAA (HR = 2.7, P = .01), and smoking status (HR = 2.9, P = .03). The risk of developing PJI increased with the high BMI (HR = 1.04, P = .03), but not surgical approach (HR = 0.68, P = .3). CONCLUSION: In this study of 16,500 primary THAs, DAA was independently associated with an elevated risk of superficial infection reoperation compared to the PLA, but there was no association between surgical approach and PJI. An elevated patient BMI was the strongest risk factor for superficial infection and PJI in our cohort. LEVEL OF EVIDENCE: III, retrospective cohort study.

Effect of anterior approach compared to posterolateral approach on readiness for discharge and thrombogenic markers in patients undergoing unilateral total hip arthroplasty: a prospective cohort study.

INTRODUCTION: The direct anterior approach (DAA) for total hip arthroplasty (THA) is considered less invasive than the posterolateral approach (PLA), possibly leading to earlier mobilization, faster recovery, and lower levels of thrombogenic markers. The purpose of the current study was to prospectively compare readiness for discharge, rehabilitation milestones, markers of thrombosis and inflammation at 6 weeks postoperatively between DAA and PLA. METHODS: A total of 40 patients (20 anterior and 20 posterolateral) were prospectively enrolled. Readiness for discharge, length of stay (LOS), and related outcomes were additionally documented. Blood was drawn at baseline, wound closure, 5-h post-closure, and 24-h post-closure for assays of interleukin-6 (IL-6), PAP (plasmin anti-plasmin), a marker of fibrinolysis, and PF1.2 (Prothrombin fragment 1.2), a marker of thrombin generation. RESULTS: Compared to the PLA group, the DAA group was ready for discharge a mean 13 h earlier (p = 0.03), while rehabilitation milestones were met a mean 10 h earlier (p = 0.04), and LOS was 13 h shorter (p = 0.02) on average. Pain scores at all study timepoints and patient satisfaction at 6 weeks were similar (p > 0.05). At 24 h postoperatively, PAP levels were 537.53 ± 94.1 µg/L vs. 464.39 ± 114.6 µg/L (p = 0.05), and Il-6 levels were 40.94 ± 26.1 pg/mL vs. 60.51 ± 33.0 pg/mL (p = 0.03), in DAA vs. PLA, respectively. CONCLUSIONS: In the immediate postoperative period, DAA patients were ready for discharge before PLA patients. DAA patients had shorter LOS, a lower inflammatory response, and higher systemic markers of fibrinolysis. However, these differences may not be clinically significant. Future studies with larger study populations are warranted to confirm the validity and significance of these findings. LEVEL OF EVIDENCE: Level II, Therapeutic Study.

Intraoperative Complications and Early Return to the Operating Room in Total Hip Arthroplasty Performed Through the Direct Anterior and Posterior Approaches. An Institutional Experience of Surgeons After Their Learning Curve.

BACKGROUND: Proponents of the direct anterior approach (DAA) for total hip arthroplasty (THA) claim a faster recovery, whereas critics claim an increased risk of early femoral complications. This study analyzed intraoperative and postoperative complications requiring reoperation within one year after THA through the DAA and posterior approach (PA). METHODS: A total of 2348 elective, unilateral DAA THAs in patients with osteoarthritis performed between 2016 and 2019 were matched 1:1 for age (±5 years), gender, body mass index (±5), and femoral fixation with 2348 patients who underwent PA THA during the same period. Mixed-effects logistic regression was used. Odds ratios were reported for the occurrence of intraoperative femoral fracture, postoperative femoral fracture, infection, dislocation, and other etiologies requiring reoperation within one year. RESULTS: Intraoperative femoral fracture occurred in 12 DAA (0.5%) and 14 PA (0.6%) patients. Twenty-five patients (1.06%) in the DAA and 28 (1.19%) in the PA group underwent reoperation within the first year. Reoperations were due to periprosthetic fracture (40%), infection (28%), dislocation (23%), and other (9%). Regression analysis revealed no difference in intraoperative femoral fracture (odds ratio (OR): 0.86, 95% confidence interval (CI): 0.40-1.86, P = .69), postoperative femoral fracture (OR: 1.10, 95% CI: 0.47-2.60, P = .83), infection (OR: 1.50, 95% CI: 0.53-5.23, P = .44), or reoperation within one year for other reasons (OR: 1.50, 95% CI: 0.25-9.00, P = .65). DAA had fewer dislocations requiring reoperation (OR: 0.20, 95% CI: 0.04-0.91, P = .02). CONCLUSION: This comparative study did not find differences in intraoperative or postoperative fracture or infection between DAA and PA. DAA was associated with a lower likelihood of reoperation for dislocation within one year of surgery.

Prospective Evaluation of the Posterior Tissue Envelope and Anterior Capsule After Anterior Total Hip Arthroplasty.

BACKGROUND: Femoral exposure for direct anterior approach (DAA) total hip arthroplasty (THA) invariably requires posterior soft tissue releases. Released posterior structures cannot be repaired. The purpose of this study is to describe the frequency and anatomic consequences of DAA THA posterior soft tissue releases and to compare the appearance of the anterior capsule between a group of patients who had capsulotomy and repair versus capsulectomy. METHODS: Thirty-two DAA THA patients underwent metal artifact reduction sequence magnetic resonance imaging at discharge and 1-year follow-up. Seventeen had underwent capsulotomy and repair and 15 capsulectomy. A radiologist blinded to intraoperative data scored each metal artifact reduction sequence magnetic resonance imaging. Anterior capsular integrity, status of the piriformis and conjoint tendons, and muscle atrophy were graded. Descriptive statistics were performed to analyze results. RESULTS: Immediately postoperatively, 75% of piriformis tendons were intact and 38% of conjoined tendons were intact. At 1 year, 97% had an intact piriformis and conjoined tendon, although many were in continuity through scar with the capsule. The posterior capsule directly contacted bone in all patients. At 1 year, none of the patients who underwent capsulotomy with repair had persistent anterior capsule defects, while 27% in the capsulectomy group had persistent defects. CONCLUSION: Posterior capsule and conjoined tendon releases were commonly performed during DAA THA, yet continuity with bone was frequently achieved at 1 year. In this study, capsulotomy with repair resulted in no anterior capsular defects when compared with capsulectomy. These results may support improved THA stability observed after DAA with capsular repair despite posterior soft tissue releases. LEVEL OF EVIDENCE: Level III, prospective cohort study.

Outcomes of Acetabular Reconstructions for the Management of Chronic Pelvic Discontinuity: A Systematic Review.

BACKGROUND: A number of articles have been published reporting on the clinical outcomes of various acetabular reconstructions for the management of chronic pelvic discontinuity (PD). However, no systematic review of the literature has been published to date comparing the outcome and complications of different approaches to reconstruction. METHODS: The US National Library of Medicine (PubMed/MEDLINE) and EMBASE were queried for publications from January 1980 to January 2019 using keywords pertinent to total hip arthroplasty, PD, acetabular dissociation, clinical or functional outcomes, and revision total hip arthroplasty or postoperative complications. RESULTS: Overall, 18 articles were included in this analysis (569 cases with chronic PD). The overall survival rate of the acetabular components used for the treatment of chronic PD was 84.7% (482 of 569 cases) at mid-term follow-up, whereas the most common reasons for revision were aseptic loosening (54 of 569 hips; 9.5%), dislocations (45 of 569 hips; 7.9%), periprosthetic joint infection (30 of 569 hips; 5.3%), and periprosthetic fractures (11 of 569 hips; 1.9%). Both pelvic distraction technique (combined with highly porous shells) and custom triflanges resulted in less than 5% failure rates (96.2% and 95.8%, respectively) at final follow-up. Also, highly effective in the treatment of PD were cup-cages and highly porous shells with and/or without augments with 92% survivorship free of revision for aseptic loosening for both reconstruction methods. Inferior outcomes were reported for conventional cementless shells combined with acetabular plates (72.7%) as well as ilioischial cages and reconstruction rings (66.7% and 60.6% survivorship, respectively). CONCLUSION: The current literature contains moderate quality evidence in support of the use of custom triflange implants and pelvic distraction techniques for the treatment of chronic PD, with a less than 5% all-cause revision rate and low complication rates at mean mid-term follow-up. Cup-cages and highly porous shells with or without augments could also be considered for the treatment of PD because both resulted in greater than 90% survival rates. Finally, there is still no consensus regarding the impact of different types of acetabular reconstruction methods on optimizing the healing potential of PD, and further studies are required in this area to better understand the influence of PD healing on construct survivorship and functional outcomes with each reconstruction method.

Comparing the Safety and Outcome of Simultaneous and Staged Bilateral Total Knee Arthroplasty in Contemporary Practice: A Systematic Review of the Literature.

BACKGROUND: Although a variety of studies have assessed the outcomes of simultaneous bilateral total knee arthroplasty (BTKA) and staged BTKA, there remains no definitive conclusion regarding the superiority of one technique in terms of safety. METHODS: The US National Library of Medicine (PubMed/MEDLINE), EMBASE, and the Cochrane Database of Systematic Reviews were queried utilizing keywords pertinent to BTKA, simultaneous and staged, and clinical or functional outcomes. In order to examine the contemporary relevant literature, studies published prior to 2009 were excluded from our search. RESULTS: In total, 19 articles met the inclusion criteria and were included in this analysis. The overall quality of the studies included in this review was rated as moderate. Seven of the 19 studies reported no significant differences between the 2 groups in regards to baseline clinical and demographic characteristics (comorbidity index, American Society of Anesthesiologists grade, preoperative clinical subjective scores). Nearly all from these 7 studies with comparable initial characteristics documented no significant differences in the overall complication rates between the 2 groups in addition to no difference in mortality rate, cardiac complications, revision rate, thromboembolic events, and functional outcomes. CONCLUSION: In contemporary studies involving comparable baseline demographics (including comorbidity index, American Society of Anesthesiologists grade), there was moderate evidence to show that simultaneous BTKA is as safe as the staged BTKA.

Preoperative Physical Therapy Education Reduces Time to Meet Functional Milestones After Total Joint Arthroplasty.

BACKGROUND: As length of stay decreases for total joint arthroplasty, much of the patient preparation and teaching previously done in the hospital must be performed before surgery. However, the most effective form of preparation is unknown. This randomized trial evaluated the effect of a one-time, one-on-one preoperative physical therapy education session coupled with a web-based microsite (preopPTEd) on patients' readiness to discharge from physical therapy (PT), length of hospital stay, and patient-reported functional outcomes after total joint arthroplasty. QUESTIONS/PURPOSES: Was this one-on-one preoperative PT education session coupled with a web- based microsite associated with (1) earlier achievement of readiness to discharge from PT; (2) a reduced hospital length of stay; and (3) improved WOMAC scores 4 to 6 weeks after surgery? METHODS: Between February and June 2015, 126 typical arthroplasty patients underwent unilateral TKA or THA. As per our institution's current guidelines, all patients attended a preoperative group education class taught by a multidisciplinary team comprising a nurse educator, social worker, and physical therapist. Patients were then randomized into two groups. One group (control; n = 63) received no further education after the group education class, whereas the intervention group (experimental; n = 63) received preopPTEd. The preopPTEd consisted of a one-time, one-on-one session with a physical therapist to learn and practice postoperative precautions, exercises, bed mobility, and ambulation with and negotiation of stairs. After this session, all patients in the preopPTEd group were given access to a lateralized, joint-specific microsite that provided detailed information regarding exercises, transfers, ambulation, and activities of daily living through videos, pictures, and text. Outcome measures assessed included readiness to discharge from PT, which was calculated by adding the number of postoperative inpatient PT visits patients had to meet PT milestones. Hospital length of stay (LOS) was assessed for hospital discharge criteria and 6-week WOMAC scores were gathered by study personnel. At our institution, to meet PT milestones for hospital discharge criteria, patients have to be able to (1) independently transfer in and out of bed, a chair, and a toilet seat; (2) independently ambulate approximately 150 feet; (3) independently negotiate stairs; and (4) be independent with a home exercise program and activities of daily living. Complete followup was available on 100% of control group patients and 100% patients in the intervention group for all three outcome measures (control and intervention of 63, respectively). RESULTS: The preopPTEd group had fewer postoperative inpatient PT visits (mean, 3.3; 95% confidence interval [CI], 3.0-3.6 versus 4.4; 95% CI, 4.1-4.7; p < 0.001) and achieved readiness to discharge from PT faster (mean, 1.6 days; 95% CI, 1.2-1.9 days versus 2.7 days; 95% CI, 2.4-3.0; p < 0.001) than the control group. There was no difference in hospital LOS between the preopPTEd group and the control group (2.4 days; 95% CI, 2.1-2.6; p = 0.082 versus 2.6 days; 95% CI, 2.4-2.8; p = 0.082). There were no clinically relevant differences in 6-week WOMAC scores between the two groups. CONCLUSIONS: Although this protocol resulted in improved readiness to discharge from PT, there was no effect on LOS or WOMAC scores at 6 weeks. Preoperative PT was successful in improving one of the contributors to LOS and by itself is insufficient to make a difference in LOS. This study highlights the need for improvement in other aspects of care to improve LOS. LEVEL OF EVIDENCE: Level II, therapeutic study.

In-Hospital Morbidity and Postoperative Revisions After Direct Anterior vs Posterior Total Hip Arthroplasty.

BACKGROUND: The direct anterior approach (DAA) offers the potential for less soft tissue insult, improved early recovery, and reduced dislocation rates. However, complications are associated with the DAA, particularly during the learning curve. We compare the DAA learning curve experience with the posterior approach regarding in-hospital complications and revision rate. METHODS: We evaluated systemic and local in-hospital complications associated with primary unilateral cementless THAs from January 1, 2010 to December 31, 2012 in 4249 patients through a posterior approach and 289 patients through a DAA. All procedures were performed consecutively by high-volume surgeons who use a single approach in a nonselective manner. The DAA was performed by surgeon transitioning from the posterior approach, thus incorporating the learning curve. Demographics were comparable. Revision procedures were captured through a minimum 4-year follow-up. Analyses compared complication and revision rates. RESULTS: The DAA group demonstrated shorter length of stay, procedure time, lower blood transfusion rate, and increased discharge to home rate. Local and major systemic in-hospital complications were rare and comparable between groups. The minor systemic complication rate was significantly greater for the posterior group (10.9% posterior vs 6.2% DAA, P < .05). Revision rate was significantly greater for the posterior group (2.7% posterior vs 0.7% DAA, P < .032). The incidence of revision for dislocation was 1.5% for the posterior approach vs 0.4% for the DAA. CONCLUSION: There was an increased rate of in-hospital minor systemic complications and overall revision, predominantly due to instability, after THA by the posterior approach, in comparison with the DAA.

Do Surgeon Expectations Predict Clinically Important Improvements in WOMAC Scores After THA and TKA?

BACKGROUND: Failure of THA or TKA to meet a patient's expectations may result in patient disappointment and litigation. However, there is little evidence to suggest that surgeons can consistently anticipate which patients will benefit from those interventions. QUESTIONS/PURPOSES: To determine the ability of surgeons to identify, in advance of surgery, patients who will benefit from THA or TKA and those who will not, where 'benefit' is defined as a clinically important improvement in a validated patient-reported outcomes score. METHODS: In this prospective study, eight high-volume orthopaedic surgeons completed validated THA and TKA expectations questionnaires (score 0-100, 100 being the highest expectation) as part of preoperative assessment of all their patients scheduled for a THA or TKA and enrolled in the Hospital for Special Surgery institutional registry. Enrolled patients completed the WOMAC preoperatively and at 2 years. Successful outcomes were defined as achieving the minimum clinically important difference (MCID) in WOMAC pain and function subscales. Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to evaluate the ability of surgeons' expectation scores to identify patients likely to achieve the MCID on the WOMAC scale. Analyses were run separately for patients having THA and TKA. We enrolled 259 patients undergoing THA and 247 undergoing TKA, of whom 77% (n = 200) and 77% (n = 191) completed followup surveys 2 years after their procedures, respectively. RESULTS: Surgeons' expectation scores effectively anticipated patients who would improve after THA, but they were no better than chance in identifying patients who would achieve the MCID on the WOMAC score 2 years after TKA. For patients having THA, the areas under the ROC curve were 0.67 (95% CI, 0.53-0.82; p = 0.02) and 0.74 (95% CI, 0.63-0.85; p < 0.01) for WOMAC function and pain outcomes, respectively, indicating good accuracy. Sensitivity and specificity were maximized on WOMAC pain and function scores (sensitivity = 0.69, specificity = 0.72, both for pain and function) at an expectations score of 83 or greater of 100. Surgeons' expectations were more accurate for patients who were men, who had a BMI less than 30 kg/m2, who had more than one comorbidity, and who were older than 65 years. For patients having TKA, surgeons' expectation scores were not better than chance for identifying those who would experience a clinically important improvement on the WOMAC scale (area under ROC curve: Function = 0.51, [95% CI, 0.42-0.61], p = 0.78; Pain = 0.51, [95% CI, 0.40-0.61], p = 0.92). CONCLUSIONS: Most patients having THA and TKA achieved the MCID improvement after surgery. However, the inability of surgeons' expectation scores to discriminate accurately between patients who benefit and those who do not among patients scheduled for THA who are young, with no comorbidities, and with elevated BMIs, and among all patients scheduled for TKA, calls for surgeons to spend more time with these patients to fully understand and address their needs and expectations. Using standardized assessment tools to compare surgeons' expectations and those of their patients may help focus the surgeon-patient discussion further, and address patients' expectations more effectively. LEVEL OF EVIDENCE: Level II, therapeutic study.

Incidence, indications, outcomes, and survivorship of stems in primary total knee arthroplasty.

PURPOSE: The indications, incidence, outcomes, and survivorship of stems in primary total knee arthroplasty (TKA) are lacking in the contemporary literature. Our hypothesis is stems in primary TKA would result in worse outcomes and survivorship. METHODS: All primary TKAs between 2007 and 2011 with 2-year follow-up were identified. Revision TKA or UKA conversion was excluded. Demographic information (age, sex, race, BMI, primary diagnosis, and Charlson-Deyo comorbidity index), outcome measures including KOOS and WOMAC, and any revisions were identified from the registry. A 2:1 matched cohort of non-stemmed/stemmed primary TKA patients was created to compare revision rates and outcomes at baseline and 2 years post-TKA. Subgroup analyses of long versus short stems, 1 versus 2 stems, and cemented versus hybrid stem fixation were completed. Two-sample t tests and Chi-square tests were used to compare conventional and stemmed TKA groups. RESULTS: The registry review included 13,507 conventional TKA and 318 stemmed TKA resulting in an incidence of 2.3 % in primary TKA. The mean follow-up was approximately 49 months in both groups. No difference was found in revision rates between stemmed TKA (2.5 %) and conventional TKA (2.2 %). Patients with post-traumatic arthritis had an odds ratio of 10.5 (95 % CI 1.2-15.3) of receiving stems. Stem length did not affect revision rates. Patients with two stems had worse KOOS and WOMAC scores at baseline which equalized to single-stem patients at 2 years. CONCLUSIONS: The use of stems may provide a survival benefit in complex primary TKA over the short term and no adverse effect on patient outcomes or satisfaction. LEVEL OF EVIDENCE: III.

Perioperative Morbidity of Same-Day and Staged Bilateral Total Hip Arthroplasty.

BACKGROUND: Management strategies for bilateral hip degenerative disease include same-day or staged bilateral total hip arthroplasty (THA), but information on outcomes remains sparse. We sought to describe in-hospital complications and blood transfusion rates after same-day and staged bilateral THAs at different time intervals and to assess risk factors for these events. METHODS: We retrospectively reviewed administrative data for 3785 patients treated with same-day bilateral (n = 1946; group A) and staged bilateral THA within (1) 0-3 months apart (n = 328; group B); (2) 3-6 months apart (n = 703; group C); and (3) 6-12 months apart (n = 808; group D), between 1999 and 2014. We recorded demographics, the Charlson-Deyo comorbidity index and in-hospital local and systemic (minor and major) complications. Complication and blood transfusion rates among groups were compared. A logistic regression model was developed to identify risk factors for major complications. RESULTS: Local complications were rare. Minor complications were less frequent in group A (P < .001). Major complications were more frequent in group D (P = .012). Group A had higher overall (P < .001) and allogeneic blood transfusion rates (P < .001) compared with the staged groups. Staged procedures within 6-12 months apart vs same-day bilateral THA, older age, Charlson-Deyo index ≥2 vs 0, and earlier vs recent admission year were associated with higher adjusted odds for major complications. CONCLUSION: Same-day bilateral THA in a high-volume joint replacement center may be a safe option for younger and healthier patients, given the relatively low incidence of adverse events reported in this study.

Duloxetine and Subacute Pain after Knee Arthroplasty when Added to a Multimodal Analgesic Regimen: A Randomized, Placebo-controlled, Triple-blinded Trial.

BACKGROUND: Duloxetine is effective for chronic musculoskeletal and neuropathic pain, but there are insufficient data to recommend the use of antidepressants for postoperative pain. The authors hypothesized that administration of duloxetine for 15 days would reduce pain with ambulation at 2 weeks after total knee arthroplasty. METHODS: In this triple-blinded, randomized, placebo-controlled trial, patients received either duloxetine or placebo for 15 days, starting from the day of surgery. Patients also received a comprehensive multimodal analgesic regimen including neuraxial anesthesia, epidural analgesia, an adductor canal block, meloxicam, and oxycodone/acetaminophen as needed. The primary outcome was the pain score (0 to 10 numeric rating scale) with ambulation on postoperative day 14. RESULTS: One hundred six patients were randomized and analyzed. On day 14, duloxetine had no effect on pain with ambulation; mean pain was 3.8 (SD, 2.3) for placebo versus 3.5 (SD, 2.1) for duloxetine (difference in means [95% CI], 0.4 [-0.5 to 1.2]; P = 0.386). Symptoms potentially attributable to duloxetine discontinuation at study drug completion (nausea, anxiety) occurred among nine patients (duloxetine) and five patients (placebo); this was not statistically significant (P = 0.247). Statistically significant secondary outcomes included opioid consumption (difference in mean milligram oral morphine equivalents [95% CI], 8.7 [3.3 to 14.1], P = 0.002 by generalized estimating equation) over the postoperative period and nausea on day 1 (P = 0.040). There was no difference in other side effects or in anxiety and depression scores. CONCLUSIONS: When included as a part of a multimodal analgesic regimen for knee arthroplasty, duloxetine does not reduce subacute pain with ambulation.

Prospective Randomized Trial of the Efficacy of Continuous Passive Motion Post Total Knee Arthroplasty: Experience of the Hospital for Special Surgery.

Conflicting evidence has created substantial controversy regarding the use of continuous passive motion (CPM) in the in-patient setting post total knee arthroplasty (TKA). A total of 109 patients were randomly assigned to two groups, CPM or no CPM, applied after TKA. All patients received the same physical therapy protocol (3 sessions per day), with the only exception being the CPM. Both groups had a knee flexion of 115° at 6 weeks and 120° at 3 months, with no significant differences (P=0.69 and P=0.41, respectively). Length of stay was significantly less for the group who did not receive CPM. The use of CPM had no clinically relevant benefits with respect to AROM, clinical outcomes or discharge disposition and was associated with a cost of $235.50 per TKA.

Intraarticular analgesia versus epidural plus femoral nerve block after TKA: a randomized, double-blind trial.

BACKGROUND: Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic. QUESTIONS/PURPOSES: We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. METHODS: Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. RESULTS: The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p < 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups. CONCLUSIONS: A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach. LEVEL OF EVIDENCE: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Perioperative morbidity and mortality of same-day bilateral TKAs: incidence and risk factors.

BACKGROUND: Controversy persists regarding the safety of same-day bilateral TKAs, and indications for same-day versus staged bilateral surgery need to be clarified. QUESTIONS/PURPOSES: We compared the (1) 30-day mortality, (2) rates of in-hospital complications, (3) in-hospital charges, and (4) risk factors for complications among patients undergoing same-day and staged bilateral TKAs at two separate admissions within 1 year either less than 3 months apart (staged 0-3) or more than 3 months apart (staged 3-12) at an institution where same-day bilateral TKAs were discouraged in patients with more severe medical comorbidities. METHODS: We analyzed institutional data from 3960 same-day, 172 staged 0-3, and 1533 staged 3-12 bilateral TKAs performed between 1998 and 2011. Patient demographics, comorbidities, and 30-day mortality were tabulated. Same-day patients were younger and healthier. Outcomes of interest included complications, blood transfusions, transfer to rehabilitation, and in-hospital charges. Regression models were conducted to identify independent risk factors for major morbidity or mortality. RESULTS: There were no differences in 30-day mortality among groups. The same-day group experienced more acute postoperative anemia, blood transfusions, and transfers to rehabilitation, but otherwise had complications comparable to those of the staged groups. In-hospital charges were lower in the same-day group. Congestive heart failure and pulmonary hypertension were the most significant factors associated with morbidity and mortality in the same-day group. CONCLUSIONS: In a high-volume subspecialty setting in which patients undergoing same-day bilateral TKAs were generally much healthier and younger, we found that same-day bilateral TKAs appeared to be safe.