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Purpose: To clarify differences in surgery duration, postoperative knee range of motion (ROM), anterior and posterior (AP) laxity, and Forgotten Joint Score (FJS) in patients undergoing medial-pivot (MP) and GRADIUS cruciate-retaining (CR) total knee arthroplasty (TKA) surgeries. Methods: We examined patients who underwent either MP or CR TKA at six different Japanese centres. Patients were propensity score matched for age, sex, and preoperative hip-knee angle (HKA). We compared the groups' average surgery duration, postoperative knee ROM, AP laxity, and FJS 1 year after surgery. Results: There were 86 study patients: 43 MP and 43 CR TKA matched for age, sex, and preoperative HKA. The MP group enjoyed a significantly shorter surgery duration (89.1 ± 10.9 mins vs. 95.7 ± 12.0 mins, p = 0.0091) and significantly better postoperative knee flexion than the CR group (123.7 ± 9.1° vs. 115.3 ± 12.4°, p < 0.001). The MP had significantly smaller postoperative AP laxity with 30° of knee flexion than the CR group (3.4 ± 1.3 vs. 5.6 ± 2.2 mm, p < 0.001). Conversely, postoperative AP laxity with 90° of knee flexion was significantly larger for the MP group (3.6 ± 1.3 vs. 2.7 ± 1.9 mm, p = 0.0098). There were no between-group differences in postoperative FJS. Conclusions: The MP group showed better postoperative knee flexion, midrange AP knee stability, and shorter surgery duration. Level of Evidence: Level III, retrospective comparative study.
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PURPOSE: To illustrate a surgical technique for augmented reality (AR)-assisted unicompartmental knee arthroplasty (UKA) and report preliminary data. METHODS: We developed an AR-based navigation system that enables the surgeon to see the tibial mechanical axis superimposed on the patient's leg in addition to the tibial cutting angle. We measured the tibial resection angle in 11 UKAs using postoperative radiographs and calculated the absolute difference between preoperative target angle and postoperative measured angle. The target angle was determined for each patient: mean values were 0.7° ± 1.0° varus in coronal alignment and 5.3° ± 1.4° posterior slope in sagittal alignment. RESULTS: The angles measured on postoperative radiographs were 2.6° ± 1.2° varus in the coronal plane and 4.8° ± 2.5° posterior slope in the sagittal plane. The absolute differences between the target and measured angles were 1.9° ± 1.5° in coronal alignment and 2.6° ± 1.2° in sagittal alignment. No patients experienced complications, including surgical site infection and periprosthetic fracture. CONCLUSION: The AR-based portable navigation system may provide passable accuracy in terms of proximal tibial resection during UKA. LEVEL OF EVIDENCE: IV.
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BACKGROUND: There have been no studies regarding the effectiveness of augmented reality (AR)-based portable navigation systems compared with accelerometer-based portable navigation systems in total hip arthroplasty (THA). METHODS: We retrospectively compared THAs performed using an AR-based portable navigation system (n = 45) and those performed using an accelerometer-based portable navigation system (n = 42). All THAs were performed with the patient in the lateral decubitus position. The primary outcome was the absolute difference between cup placement angles displayed on the navigation screen and those measured on postoperative X-ray. RESULTS: The mean absolute differences were significantly smaller in the AR-based portable navigation system group than the accelerometer-based portable navigation system group in radiographic inclination (2.5° ± 1.7° vs 4.6° ± 3.1°; 95% confidence interval 1.1°-3.2°, P < .0001). Similarly, the mean absolute differences were significantly better in the AR-based portable navigation system group in radiographic anteversion (2.1° ± 1.8° vs 6.4° ± 4.2°; 95% confidence interval 3.0°-5.7°, P < .0001). Neither hip dislocation, surgical site infection, nor other complications associated with use of the navigation system occurred in either group. CONCLUSION: The AR-based portable navigation system may provide more precise acetabular cup placement compared with the accelerometer-based portable navigation system in THA.
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Artroplastia de Quadril , Realidade Aumentada , Prótese de Quadril , Cirurgia Assistida por Computador , Acelerometria , Acetábulo/diagnóstico por imagem , Acetábulo/cirurgia , Humanos , Estudos RetrospectivosRESUMO
AIMS: Although periarticular injection plays an important role in multimodal pain management following total hip arthroplasty (THA), there is no consensus on the optimal composition of the injection. In particular, it is not clear whether the addition of a corticosteroid improves the pain relief achieved nor whether it is associated with more complications than are observed without corticosteroid. The aim of this study was to quantify the safety and effectiveness of cortocosteroid use in periarticular injection during THA. METHODS: We conducted a prospective, two-arm, parallel-group, randomized controlled trial involving patients scheduled for unilateral THA. A total of 187 patients were randomly assigned to receive periarticular injection containing either a corticosteroid (CS group) or without corticosteroid (no-CS group). Other perioperative interventions were identical for all patients. The primary outcome was postoperative pain at rest during the initial 24 hours after surgery. Pain score was recorded every three hours until 24 hours using a 100 mm visual analogue scale (VAS). The primary outcome was assessed based on the area under the curve (AUC). RESULTS: The CS group had a significantly lower AUC postoperatively at 0 to 24 hours compared to the no-CS group (AUC of VAS score at rest 550 ± 362 vs 392 ± 320, respectively; mean difference 158 mm; 95% confidence interval (CI) 58 to 257; p = 0.0021). In point-by-point evaluation, the CS group had significantly lower VAS scores at 12, 15, 18, 21, 24, and 48 hours. There were no significant differences in complication rates, including surgical site infection, between the two groups. CONCLUSION: The addition of corticosteroid to periarticular injections reduces postoperative pain without increasing complication rate following THA. Cite this article: Bone Joint J 2020;102-B(10):1297-1302.
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Corticosteroides/uso terapêutico , Artroplastia de Quadril , Dor Pós-Operatória/prevenção & controle , Idoso , Anestesia Geral , Método Duplo-Cego , Feminino , Humanos , Injeções Intra-Articulares , Masculino , Pessoa de Meia-Idade , Medição da Dor , Estudos ProspectivosRESUMO
BACKGROUND: Combined intraoperative intravenous and intra-articular tranexamic acid (TXA) is 1 of the most effective administration routes to decrease the amount of perioperative blood loss during total knee arthroplasty (TKA). However, the additive effect of postoperative intravenous TXA administration remains unclear. We hypothesized that the postoperative repeated-dose intravenous administration of TXA would provide lower perioperative blood loss. METHODS: We performed a double-blinded, placebo-controlled trial involving patients undergoing primary TKA. A total of 100 patients who were managed with combined intraoperative intravenous and intra-articular TXA were randomly assigned to receive 3 postoperative 1,000-mg doses of intravenous TXA (TXA group) or 3 postoperative doses of intravenous normal saline solution (placebo group) in a 1:1 ratio. The prespecified primary outcome was perioperative blood loss calculated from patient blood volume and the difference in hemoglobin from preoperatively to postoperative day 3. A post hoc power analysis showed that the number of patients allocated to either the TXA group (n = 46) or the placebo group (n = 54) possessed >80% power to detect a 200-mL difference in perioperative blood loss. RESULTS: In the intention-to-treat analysis, we found no significant differences in perioperative blood loss between the TXA group and the placebo group through postoperative day 3 (578 ± 229 compared with 640 ± 276 mL, respectively; 95% confidence interval for the difference, -40 to 163 mL; p = 0.23). The prevalence of postoperative thrombotic events did not differ between the 2 groups (4.3% compared with 3.7%, respectively; p > 0.99). CONCLUSIONS: Postoperative intravenous TXA had no additive effect in reducing perioperative blood loss in patients receiving intraoperative combined intravenous and intra-articular TXA. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Antifibrinolíticos/administração & dosagem , Artroplastia do Joelho , Perda Sanguínea Cirúrgica/prevenção & controle , Ácido Tranexâmico/administração & dosagem , Administração Intravenosa , Idoso , Método Duplo-Cego , Feminino , Humanos , Injeções Intra-Articulares , Análise de Intenção de Tratamento , MasculinoRESUMO
INTRODUCTION: Although soft tissue tension during total knee arthroplasty (TKA) has been targeted to achieve equal flexion and extension gaps, such a perfect gap is not always obtained. This study was performed to investigate the impact of difference between flexion and extension gaps on postoperative knee flexion angle. MATERIALS AND METHODS: We reviewed 107 consecutive TKAs using a J-curve design posterior-stabilized prosthesis. Soft tissue tension was measured intraoperatively using an offset-type tensor under 30 lb force of joint distraction with the patella reduced. All TKAs were performed in a uniform manner including the subvastus approach and without use of a pneumatic tourniquet. We assessed the association between knee flexion angle 1 year after TKA and the difference between flexion and extension gaps using Pearson's product-moment correlation and multiple regression analysis with age, sex, body mass index, diagnosis, history of diabetes mellitus, preoperative flexion angle, and gap difference as explanatory variables. RESULTS: The difference between flexion and extension gaps showed a slight negative correlation with postoperative knee flexion angle in univariate analysis (r = - 0.20, 95% CI, - 0.38 to - 0.01, p = 0.04). Multiple regression analysis showed that the gap difference was an independent factor associated with postoperative knee flexion angle (ß = - 0.89, 95% CI, - 1.60 to - 0.18, p = 0.01). CONCLUSIONS: The difference between flexion and extension gaps was negatively correlated with postoperative knee flexion angle. Looser flexion gap compared with extension gap should be avoided in J-curve design posterior-stabilized TKA.
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Artrometria Articular/métodos , Artroplastia do Joelho/métodos , Instabilidade Articular/prevenção & controle , Monitorização Intraoperatória/métodos , Osteoartrite do Joelho/cirurgia , Amplitude de Movimento Articular/fisiologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Humanos , Japão , Prótese do Joelho , Masculino , Análise Multivariada , Osteoartrite do Joelho/diagnóstico por imagem , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Desenho de Prótese , Análise de Regressão , Resultado do TratamentoRESUMO
BACKGROUND: This pilot study was performed to examine the accuracy of the AR-KNEE system, an imageless navigation system using augmented reality (AR) technology for total knee arthroplasty. The AR-KNEE system enables the surgeon to view information from the navigation superimposed on the surgical field on a smartphone screen in real time. METHODS: Using the AR-KNEE system, one surgeon resected 10 tibial sawbones with viewing the tibial axis and aiming varus/valgus, posterior slope, internal/external rotation angles, and resection level superimposed on the surgical field. We performed computed tomography of the resected sawbones and measured the varus/valgus, posterior slope, and internal/external rotation angles using a designated computer software. The thickness of the resected bone was measured using digital calipers. RESULTS: The absolute differences between the values displayed on the smartphone screen and the measurement values for varus/valgus, posterior slope, internal/external rotation angles, and thickness of the resected bone were 0.5° ± 0.2°, 0.8° ± 0.9°, 1.8° ± 1.5°, and 0.6 mm ± 0.7 mm, respectively. CONCLUSIONS: This pilot study using sawbones suggested that the AR-KNEE system may provide reliable accuracy for coronal, sagittal, and rotational alignment in tibial bone resection during total knee arthroplasty.
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BACKGROUND: Intra-articular tranexamic acid (TXA) as an adjunct to intravenous TXA was reported to decrease perioperative blood loss during unilateral total knee arthroplasty (TKA). However, there have been no randomized controlled trials comparing intravenous versus combined intravenous and intra-articular TXA administration in patients undergoing simultaneous bilateral TKA. METHODS: We randomly assigned 77 patients with 154 involved knees undergoing simultaneous bilateral TKA to the intravenous TXA group (intra-articular placebo for each knee) or combined TXA group (1000 mg of intra-articular TXA for each knee) with 1:1 treatment allocation. In both groups, 1000 mg of TXA was given intravenously twice, just before surgery and 6 h after the initial administration. Other perioperative medications, surgical procedures, and blood management strategies were the same for all patients. The primary outcome was perioperative blood loss calculated from blood volume and change in hemoglobin from preoperative to postoperative day 3. RESULTS: Intention-to-treat analysis showed no statistically significant differences in perioperative blood loss until postoperative day 3 (1067 ± 403 mL in the intravenous TXA group vs. 997 ± 345 mL in the combined TXA group [95% CI, - 240 to 100 mL], P = 0.42). No patients required allogenic blood transfusion. The incidence of thrombotic events did not differ between groups (12% in the intravenous TXA group vs. 9% in the combined TXA group; P = 0.73). CONCLUSIONS: The addition of intra-articular TXA did not reduce perioperative blood loss in patients undergoing simultaneous bilateral TKA compared with placebo. TRIAL REGISTRATION: University Hospital Medical Information Network UMIN000026137 . Registered 14 February 2017.
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Osteoartrite do Joelho/tratamento farmacológico , Ácido Tranexâmico/administração & dosagem , Administração Intravenosa , Idoso , Idoso de 80 Anos ou mais , Artroplastia do Joelho , Quimioterapia Adjuvante , Método Duplo-Cego , Feminino , Humanos , Injeções Intra-Articulares , MasculinoRESUMO
PURPOSE: This study was performed to determine whether periarticular injection performed in the early stage of total knee arthroplasty (TKA) could provide a better postoperative pain relief than periarticular injection performed in the late stage of TKA. The hypothesis was based on the concept that analgesic intervention before the onset of noxious stimuli would be associated with less postoperative pain. METHODS: A total of 105 participants were randomly assigned to receive superficial injection just prior to arthrotomy (early stage periarticular injection group) or superficial injection after implanting the prosthesis (late-stage periarticular injection group) in patients undergoing unilateral TKA with 1:1 treatment allocation. In both groups, deep injection was performed according to the same schedule (just prior to implanting prosthesis). The solution consisted of 300 mg of ropivacaine, 8 mg of morphine, 40 mg of methylprednisolone, 50 mg of ketoprofen, and 0.3 mg of epinephrine mixed with normal saline to a final volume of 60 mL. All surgeries were managed under general anesthesia without any regional blocks. Registry-specified primary outcome was postoperative pain score at rest measured at the recovery room using a 100-mm visual analog scale (VAS). The VAS score was compared between two groups and assessed to reach the reported threshold values for the minimal clinically important difference (MCID) of 10 mm for the postoperative VAS score. RESULTS: The VAS score at the recovery room was significantly lower in the early stage periarticular injection group than the late-stage periarticular injection group (23 ± 25 mm versus 39 ± 34 mm, respectively; 95% confidence interval 4-28 mm; p = 0.0078). The mean difference in the primary outcome fulfilled the MCID value. CONCLUSIONS: Bringing forward the timing of periarticular injection may provide significant and clinically meaningful improvement in pain following TKA under general anesthesia. LEVEL OF EVIDENCE: I.
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Anestésicos Locais/administração & dosagem , Artroplastia do Joelho , Injeções Intra-Articulares , Dor Pós-Operatória/tratamento farmacológico , Idoso , Analgésicos/administração & dosagem , Anestesia Geral , Esquema de Medicação , Epinefrina/administração & dosagem , Feminino , Humanos , Cetoprofeno/administração & dosagem , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Estudos Prospectivos , Ropivacaina/administração & dosagem , Resultado do TratamentoRESUMO
BACKGROUND: Anterolateral skin incision can preserve the skin sensory of the anterior aspect of the knee and may improve kneeling ability after total knee arthroplasty (TKA). METHODS: This is a prospective, 2-arm, parallel-group, randomized, controlled trial involving patients scheduled for TKA. A total of 118 patients (162 knees) were randomly assigned to receive anterolateral skin incision or anteromedial skin incision with 1:1 treatment allocation. The surgical techniques other than skin incision were identical in both groups. The area of cutaneous hypesthesia was measured by a nonblinded assessor, and kneeling ability was evaluated by 2 blinded assessors at 12 months after surgery. RESULTS: The area of cutaneous hypesthesia was significantly smaller in the anterolateral skin incision group than the anteromedial skin incision group (3.0 ± 8.7 cm2 vs 10.6 ± 18.6 cm2; 95% confidence interval, 2.8-12.3 cm2; P = .0019). The rates of patients judged to be able to kneel were significantly higher in the anterolateral skin incision group by both assessors (81% vs 60%; P = .025 and 81% vs 59%; P = .015, respectively) with almost perfect agreement between the 2 assessors (kappa value = 0.94). There were no significant differences in terms of complication rate, including wound complications, between the 2 groups (P > .05). CONCLUSION: Compared with anteromedial skin incision, anterolateral skin incision may provide less cutaneous hypesthesia and better kneeling ability after TKA without increasing complication rate.