Can therapy dogs improve pain and satisfaction after total joint arthroplasty? A randomized controlled trial.

BACKGROUND: The use of animals to augment traditional medical therapies was reported as early as the 9th century but to our knowledge has not been studied in an orthopaedic patient population. The purpose of this study was to evaluate the role of animal-assisted therapy using therapy dogs in the postoperative recovery of patients after THA and TKA. QUESTIONS/PURPOSES: We asked: (1) Do therapy dogs have an effect on patients' perception of pain after total joint arthroplasty as measured by the VAS? (3) Do therapy dogs have an effect on patients' satisfaction with their hospital stay after total joint arthroplasty as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)? METHODS: A randomized controlled trial of 72 patients undergoing primary unilateral THA or TKA was conducted. Patients were randomized to a 15-minute visitation with a therapy dog before physical therapy or standard postoperative physical therapy regimens. Both groups had similar demographic characteristics. Reduction in pain was assessed using the VAS after each physical therapy session, beginning on postoperative Day 1 and continuing for three consecutive sessions. To ascertain patient satisfaction, the proportion of patients selecting top-category ratings in each subsection of the HCAHPS was compared. RESULTS: Patients in the treatment group had lower VAS scores after each physical therapy session with a final VAS score difference of 2.4 units (animal-assisted therapy VAS, 1.7; SD, 0.97 [95% CI, 1.4-2.0] versus control VAS, 4.1; SD, 0.97 [95% CI, 3.8-4.4], p<0.001) after the third physical therapy session. Patients in the treatment group had a higher proportion of top-box HCAHPS scores in the following fields: nursing communication (33 of 36, 92% [95% CI, 78%-98%] versus 69%, 25 of 36 [95% CI, 52%-84%], p=0.035; risk ratio, 1.3 [95% CI of risk ratio, 1.0-1.7]; risk difference, 23% [95% CI of risk difference, 5%-40%]), pain management (34 of 36, 94% [95% CI, 81%-99%], versus 26 of 36, 72% [95% CI, 55%-86%], p=0.024; risk ratio, 1.3 [95% CI of risk ratio, 1.1-1.6]; risk difference, 18% [95% CI of risk difference, 5%-39%]). The overall hospital rating also was greater in the treatment group (0-10 scale) (9.6; SD, 0.7 [95% CI, 9.3-9.8] versus 8.6, SD, 0.9 [95% CI, 8.3-8.9], p<0.001). CONCLUSIONS: The use of therapy dogs has a positive effect on patients' pain level and satisfaction with hospital stay after total joint replacement. Surgeons are encouraged to inquire about the status of volunteer-based animal-assisted therapy programs in their hospital as this may provide a means to improve the immediate postoperative recovery for a select group of patients having total joint arthroplasty. LEVEL OF EVIDENCE: Level II, randomized controlled study. See Instructions for Authors for a complete description of levels of evidence.

Resolution of Preoperative Peroneal Nerve Palsy After Total Knee Arthroplasty: A Case Report.

CASE: We present the case of a 71-year-old man with right knee osteoarthritis (OA) and a varus deformity who developed a progressive common peroneal nerve palsy that resolved after total knee arthroplasty (TKA). After decades of knee pain, the patient gradually developed a foot drop as well as numbness and paresthesias over the foot dorsum during the course of 1 month. The patient underwent TKA and within 6 weeks postoperatively had complete resolution of the peroneal nerve symptoms. CONCLUSION: A progressive common peroneal palsy in advanced varus knee OA may resolve after a properly aligned TKA without nerve decompression.

Treatment of advanced primary and recurrent diffuse pigmented villonodular synovitis of the knee.

BACKGROUND: Diffuse pigmented villonodular synovitis of the knee is a difficult tumor to eradicate. We report our experience with a combined open posterior and anterior synovectomy with and without adjuvant postoperative radiation therapy in patients with advanced extracapsular disease. METHODS: A single surgeon operated on forty patients, with an average age of thirty-five years (range, fourteen to sixty-eight years), who had diffuse pigmented villonodular synovitis of the knee. All patients had been referred to us after having initially undergone arthroscopic or open surgical procedures without eradication of the disease. Patients were retrospectively placed into one of three groups: Group I received surgery alone (five patients), Group II had surgery and intra-articular radiation synovectomy with use of dysprosium-165 (thirty patients), and Group III had surgery and external beam radiation (five patients). Adjuvant radiation was performed three months postoperatively. Magnetic resonance imaging was used for all patients for preoperative staging and postoperative follow-up. RESULTS: The average Knee Society score for the entire series improved from 61 points preoperatively to 92 points at the time of follow-up, at an average of five years (range, 1.5 to eight years) (p < 0.001). There was also a significant (p < 0.001) increase in the average range of motion of the knees across all groups. On the basis of the Knee Society scores, thirty-seven patients (93%) had a good or excellent result, two patients had a fair result, and one patient had a poor result. Complications included stiffness requiring manipulation in three knees, one case of reflex sympathetic dystrophy, advanced osteoarthritis leading to a total knee replacement in four patients, and seven recurrences (a prevalence of 18%) after operative treatment and radiation therapy. CONCLUSIONS: This surgical technique allows excellent visualization and removal of intra-articular and extra-articular diffuse pigmented villonodular tissue and yields excellent functional results and a low prevalence of knee stiffness. However, the rate of recurrence detected by magnetic resonance imaging was 18%. Adjuvant intra-articular radiation therapy may be beneficial for eradication of small foci of residual disease, but complete resection of all pigmented villonodular tissue appears to be the key to preventing recurrence. Magnetic resonance imaging was essential for accurate preoperative staging of the tumor and for follow-up since the presence of residual disease did not reliably correlate with the clinical findings. Patients with minimal degenerative arthritis and primary or recurrent extra-articular disease will benefit most from this approach.

Lubricin and smooth muscle α-actin-containing myofibroblasts in the pseudomembranes around loose hip and knee prostheses.

The objective was to evaluate the presence and distribution of the lubricating and anti-adhesion glycoprotein lubricin and cells containing the contractile isoform smooth muscle α-actin (SMA) in pseudomembranes around loose hip prostheses. Periprosthetic tissue was obtained at revision arthroplasty of eight aseptic, loose hip implants, and for comparison three loose knee prostheses. Immunohistochemical analysis was performed in 3 zones: zone 1, within 300µm of the edge of the implant-tissue interface; zone 2, between zones 1 and 3; zone 3, within 300µm of the resected/trimmed edge. The presence of lubricin was extensive in all samples: (1) as a discrete layer at the implant-tissue interface; (2) within the extracellular matrix (ECM); (3) intracellularly. There was significantly more high grade (>50%) lubricin surface staining at the implant-tissue interface compared with the resected edge. While there was also a significant effect of location of high grade ECM lubricin staining, there was no significant effect of implant type (i.e. hip versus knee). All but two hip pseudomembrane samples showed the presence of many SMA-containing cells. There was a significant effect of location on the number of SMA-expressing cells, but not of implant type. These findings might explain why the management of loose prosthesis is so challenging.

Extraarticular pigmented villonodular synovitis: a cause for failed knee arthroscopy.

Arthroscopic treatment of diffuse pigmented villonodular synovitis of the knee is reported to have low recurrence rates and morbidity. The purpose of the current study was to evaluate demographic information, clinical symptoms, treatment parameters, and functional outcome in a group of 38 consecutive patients referred to the authors' hospital with persistent extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. There were 23 males and 15 females with an average age of 31.7 years (range, 11-65 years) at the time of arthroscopy. All had an average of 1.7 (range, 1-5) arthroscopies. Thirty-four of 38 (89.5%) patients had some improvements of their symptoms after arthroscopic synovectomy, but all had worse symptoms and function at the latest followup of 3.63 years (range, 0.25-19.5 years). Although arthroscopic synovectomy offered some short-term relief, a critical review of prior reports and the data in the current study suggest poor outcomes in patients who have extraarticular diffuse pigmented villonodular synovitis of the knee after arthroscopic synovectomy. Magnetic resonance imaging is recommended for accurate staging of the disease and for long-term followup after arthroscopic treatment.