Bone health and hyperglycemia in pediatric populations.

The impact of prediabetes and diabetes on skeletal health in the context of increased risk of fragility fractures in adults has been studied recently. However, the prevalence of diabetes, overweight, and obesity have also increased in younger subjects. Current data concerning bone metabolism based on assessment of markers for bone turnover and of bone quality in diabetes patients in diverse age groups appears to be inconsistent. This review synthesizes the current data on the assessment of bone turnover based on the use of circulating bone markers recommended by international organizations; the effects of age, gender, and other factors on the interpretation of the data; and the effects of type 1 and type 2 diabetes as well as hyperglycemia on bone quality and turnover with particular emphasis on the pediatric population. Early intervention in the pediatric population is necessary to prevent the progression of metabolic disturbances that accompany prediabetes and diabetes in the context of common low vitamin D status that may interfere with bone growth.

Polish adaptation and validation of the hip disability and osteoarthritis outcome score (HOOS) in osteoarthritis patients undergoing total hip replacement.

BACKGROUND: The Hip disability and Osteoarthritis Outcome Score (HOOS) is a frequently used patient-reported outcome measure (PROM) for assessment of hip disorders and treatment effects following hip surgery. The objective of the study was to translate and adapt the Hip disability and Osteoarthritis Outcome Score (HOOS) into Polish and to investigate the psychometric properties of the HOOS in patients with osteoarthritis undergoing total hip replacement (THR). MATERIALS AND METHODS: The Polish version of the HOOS was developed according to current guidelines. Patients completed the HOOS, Short Form 36 Health Survey (SF-36), the visual analogue scale (VAS) for pain and the global perceived effect (GPE) scale. Psychometric properties including interpretability (floor/ceiling effects), internal consistency (Cronbach's alpha), test-retest reliability (intra-class correlation coefficient, ICC), convergent construct validity (a priori hypothesized Spearman's correlations between the HOOS subscales, the generic SF-36 measure and the VAS for pain) and responsiveness (effect size, association between the HOOS and GPE scores) were analyzed. RESULTS: The study included 157 patients (mean age 66.8 years, 54% women). Floor effects were found prior to THR for the HOOS subscales Sports and Recreation and Quality of Life. The Cronbach's alpha was over 0.7 for all subscales indicating satisfactory internal consistency. The test-retest reliability was good for the HOOS subscale Pain (0.82) and excellent for all other subscales with ICCs ranging from 0.91 to 0.96. The minimal detectable change ranged from 12.0 to 26.2 on an individual level and from 1.4 to 3.0 on a group level. Seven out of eight a priori hypotheses were confirmed indicating good construct validity. Responsiveness was high since the expected pattern of effect sizes in all subscales was found. CONCLUSIONS: The Polish version of the HOOS demonstrated good reliability, validity and responsiveness for use in patient groups having THR.

Cross-cultural translation and measurement properties of the Polish version of the Knee injury and Osteoarthritis Outcome Score (KOOS) following anterior cruciate ligament reconstruction.

BACKGROUND: Knee Injury and Osteoarthritis Outcome Score (KOOS) is available in over 30 languages and a commonly used Patient-Reported Outcome (PRO) for assessment of treatment effects following knee surgery. The aim of the study was to report the linguistic translational process and evaluate the psychometric properties of the Polish version of the KOOS questionnaire. METHODS: We translated and culturally adapted the KOOS according to current guidelines for use in Poland. Patients who had undergone anterior cruciate ligament reconstruction (ACLR) completed the KOOS and Short Form 36 Health Survey (SF-36). We evaluated floor/ceiling effects, reliability (using Cronbach's alpha, intraclass correlation coefficients (ICC) and measurement error), convergent and divergent construct validity (using four a priori stated hypotheses) and responsiveness (using data obtained prior to and one year after ACLR and described by both effect size (ES) and standardized response mean (SRM)). RESULTS: The clinical study population consisted of 72 subjects (mean age 29.8, 28% women). We did not observe floor effects in any KOOS subscales neither pre- nor postoperatively. As expected, ceiling effects were found postoperatively for the subscales Pain and ADL in this cohort assessed on average 1.3 year after surgery as more than 15% reported no pain or limitations in daily activities. The Cronbach's alpha was above 0.9 for all subscales indicating excellent internal consistency. The test-retest reliability of all KOOS subscales at one-year postoperatively was excellent with ICCs exceeding 0.86 for all subscales. The minimal detectable change on group level ranged from 1.3 to 2.4, and on an individual level from 10.9 to 20.2. Responsiveness was demonstrated since the expected pattern of effect sizes between subscales following ACLR was found. CONCLUSIONS: We found the Polish version of the KOOS to be a valid and reliable instrument for use in patient groups having ACLR. We caution against monitoring individual patients since the smallest change considered clinically relevant cannot reliably be detected.

Diagnostic Performance of Biomarker-Based Scores as Predictors of Metabolic Dysfunction-Associated Fatty Liver Disease Risk in Healthy Children.

INTRODUCTION: Metabolic dysfunction-associated fatty liver disease (MAFLD)-a new definition for non-alcoholic fatty liver disease-reflects the impact of metabolic abnormalities on liver function. We assessed the diagnostic accuracy of biomarker-based scores for prediction of MAFLD in apparently healthy children. METHODS: This study included 144 children aged 9-11. MAFLD was recognized in 14 girls and 29 boys. Anthropometric indices, glycemia, insulin resistance, lipid profile, enzymes (ALT, AST, GGT, ALP), CRP, N-terminal propeptide of type I procollagen (P1NP) and collagen type I C-telopeptide (CTX-1) levels were measured. Fatty liver and hepatic steatosis index (FLI, HSI) and potential indicators of liver fibrogenesis: P1NP/ALP, P1NP/ALPxALT, P1NP/ALPxCRP were calculated. RESULTS: P1NP/ALPxALT and P1NP/ALPxCRP were significantly higher in subjects with MAFLD. FLI was a good, significant predictor of MAFLD occurrence, regardless of sex. In boys, P1NP/ALPxCRP was a comparable predictor as CRP (OR 1.14 vs. 1.17; p < 0.001). P1NP/ALPxCRP had better discrimination capability in boys (AUC = 0.79; p < 0.001). However, the use of this algorithm did not improve discriminatory power in comparison to CRP (AUC = 0.81; p < 0.001), but gave a better sensitivity for MAFLD prediction (86% vs. 59%). CONCLUSIONS: We suggest that P1NP/ALPXCRP is a reliable tool for MAFLD prediction in routine pediatric practice.

Multi-stage treatment for malunion and avascular necrosis of the femoral head following reverse oblique pertrochanteric fracture: A case report and literature review.

Femoral reverse oblique intertrochanteric fractures are successfully treated using intramedullary devices. Poor fracture reduction and the use of the inaproppriate implant can lead to implant failure and subsequent malunion or non-union. We present the case of a 21-year-old polytrauma female who, among other injuries, sustained a reverse oblique intertrochanteric fracture that was primarily operated on with the dynamic hip screw. After implant failure the patient developed malunion with bone defect and avascular necrosis of the femoral head. Successful salvage of the bone stock in the inter- and subtrochanteric region was achieved using the two-stage induced membrane technique. The uncemented total hip arthroplasty was performed to address the osteonecrosis of the femoral head.

Relationships between Bone Turnover Markers and Factors Associated with Metabolic Syndrome in Prepubertal Girls and Boys.

The associations between individual components of metabolic syndrome (MetS) and bone health in children are complex, and data on this topic are sparse and inconsistent. We assessed the relationship between bone turnover markers and markers of the processes underlying MetS (insulin resistance and inflammation) in a group of presumably healthy children aged 9-11 years: 89 (51 girls, 38 boys) presenting without any features of MetS and 26 (10 girls, 16 boys) with central obesity and two features of MetS. Concentrations of glucose, triglycerides (TG), HDL cholesterol (HDL-C), C-reactive protein (CRP), HbA1c, total 25-hydroxyvitamin D (25(OH)D), intact-P1NP (N-terminal propeptide of type I procollagen), CTX-1 (C-terminal telopeptide of type I collagen) were assayed and insulin resistance was assessed (HOMA-IR). BMI centile, waist circumference (WC) and blood pressure were measured. The presence of MetS in girls resulted in significantly lower concentrations of CTX-1 and a trend to lower CTX-1 in boys. The concentrations of bone formation marker i-P1NP were not affected. Among the features associated with MetS, HOMA-IR appeared as the best positive predictor of MetS in girls, whereas CRP was the best positive predictor in boys. A significant influence of HOMA-IR on the decrease in CTX-1 in girls was independent of BMI centile and WC, and the OR of having CTX-1 below the median was 2.8-fold higher/1SD increased in HOMA-IR (p = 0.003). A weak relationship between CTX-1 and CRP was demonstrated in girls (r = -0.233; p = 0.070). Although TG, as a MetS component, was the best significant predictor of MetS in both sexes, there were no correlations between bone markers and TG. We suggest that dyslipidemia is not associated with the levels of bone markers in prepubertal children whereas CRP is weakly related to bone resorption in girls. In prepubertal girls, insulin resistance exerts a dominant negative impact on bone resorption, independent of BMI centile and waist circumference.

Short-term patient-reported outcomes following total hip replacement: Is the success picture overrated?

Objectives: Our objective was report short-term results of total hip replacement (THR) and to identify patients with functional recovery and with treatment failure. We also aimed to investigate whether there are any potential predicting factors for functional recovery or treatment failure. Design: Prospective cohort study. Clinical examination was performed and data were collected from patients before THR and at three follow-up assessments within subsequent year. The primary endpoint was the change between assessments in the average score on four subscales of the Hip disability and Osteoarthritis Outcome Score (HOOS4) covering pain, symptoms, activity of daily living, and quality of life. Secondary endpoints included results on all five HOOS subscales, and the SF-36. Functional Recovery and Treatment Failure were defined basing on the published reference population values. Results: We assessed 179 patients (98 women and 81 men, mean age at THR 67 years, range 31-90 years). The mean HOOS4 scores continued to improve up to 12 months after THR. Functional Recovery was identified in 32% while Treatment Failure in 16% of the patients. We found an association between high (>30.3) preoperative SF-36 Physical Component Summary scores and Functional Recovery, as well as low preoperative SF-36 Physical (<30.3) and Mental (<35.9) Component Summary scores and Treatment Failure. Conclusions: Knowing that only one third of subjects undergoing THR achieved Functional Recovery and one sixths had Treatment Failure, gives us a better perspective to discuss feasibility of expectations and, consequently, to prevent patient dissatisfaction following THR.

Prediction of improvement after anterior cruciate ligament reconstruction.

OBJECTIVE: The retrospective investigation was carried out to assess whether subjects who fulfilled our proposed recruitment criteria responded more favorably to anterior cruciate ligament reconstruction (ACLR) than those who did not. METHODS: We retrospectively analyzed 109 skeletally mature subjects (78 men and 31 women) according to the following proposed criteria of recruitment: (1) pre-injury Tegner activity score ≥7 and a wish to return to a professional sports activity, (2) residual knee instability following injury and/or (3) age <20 years at the operation. The primary outcome was an improvement between assessment A (before operation) and B (mean follow-up of 1.6 years) in the average score for four of the five Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, covering pain, symptoms, difficulty in sports and recreational activities, and quality of life (KOOS4). RESULTS: The proposed recruitment criteria for ACLR were met by 58 subjects (53%). There were 49 subjects (45%) who improved between assessment A and B. Subjects who met proposed recruitment criteria were more likely to improve clinically after ACLR (OR 5.7, 95% CI 2.5-13.3). CONCLUSIONS: Fulfillment of proposed recruitment criteria was a strong predictive factor for outcome improvement in short- to medium-term follow-up after ACLR. LEVEL OF EVIDENCE: Case-control study. Level of evidence 3.

Low Serum 25-hydroxyvitamin D Level Does Not Adversely Affect Bone Turnover in Prepubertal Children.

Both vitamin D and insulin-like growth factor 1 (IGF-1) play essential roles in bone metabolism and may interact during prepubertal bone accrual. We investigated the association of low serum 25-hydroxyvitamin D (25(OH)D) (<20 ng/mL) with the circulating bone turnover markers, when compared to their interaction with IGF-1. SUBJECTS AND METHODS: Serum 25(OH)D, IGF-I, P1NP (N-terminal propeptide of type I procollagen), and CTX-1 (C-terminal telopeptide of type I collagen) were measured, and the bone turnover index (BTI) was calculated in 128 healthy children, aged 9-11 years. RESULTS: Mean 25(OH)D concentration was 21.9 ± 4.9 ng/mL, but in 30.5% of participants it was <20 ng/mL (<50 nmol/L). We observed a trend for higher P1NP (p < 0.05) and IGF-1 (p = 0.08), towards lower 25(OH)D in tertiles. Levels of P1NP in the lowest 25(OH)D tertile (<20 ng/mL) were the highest, while CTX and BTI remained unchanged. Additionally, 25(OH)D negatively correlated with IGF-1, while the correlation with P1NP was not significant. A strong positive correlation of IGF-1 with P1NP and BTI but weak with CTX was observed. Low 25(OH)D (<20 ng/mL) explained 15% of the IGF-1 variance and 6% of the P1NP variance. CONCLUSIONS: Low levels of 25(OH)D do not unfavorably alter bone turnover. It seems that serum 25(OH)D level may not be an adequate predictor of bone turnover in children.

Effect of fasting hyperglycemia and insulin resistance on bone turnover markers in children aged 9-11 years.

AIM: Impaired regulation of glucose metabolism in childhood adversely affects bone health. We assessed the effect of fasting hyperglycemia and insulin resistance on bone turnover markers in prepubertal children with normal glycemia (<100 mg/dL) and fasting hyperglycemia (100-125 mg/dL). METHODS: Glucose, hemoglobin A1c, IGF-I (insulin-like growth factor I), iP1NP (N-terminal propeptide of type I procollagen), CTX-1 (C-terminal telopeptide of type I collagen) and insulin were measured. Bone turnover index (BTI) and HOMA-IR (homeostasis model assessment) were calculated. RESULTS: Bone resorption marker (CTX) levels were decreased by 26.5% in boys with hyperglycemia, though only 7% in girls. Hyperglycemia had no effect on the bone formation marker iP1NP. IGF-1, the best predictor of bone marker variance accounted for 25% of iP1NP and 5% of CTX variance. Girls presented significantly higher BTI indicating the predominance of bone formation over resorption. Insulin resistance significantly decreased CTX. In girls, HOMA-IR and IGF-1 predicted 15% of CTX variance. CONSLUSIONS: Fasting hyperglycemia and insulin resistance in children impact bone turnover suppressing bone resorption. Hyperglycemia decreased resorption, particularly in boys, while suppression of resorption by insulin resistance was more pronounced in girls. We suggest that the progression of disturbances accompanying prediabetes, may interfere with bone modelling and be deleterious to bone quality in later life.

Knee complaints vary with age and gender in the adult population. Population-based reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS).

BACKGROUND: Self-reported knee complaints may vary with age and gender. Reference data from the adult population would help to better interpret the outcome of interventions due to knee complaints. The objectives of the present study were to describe the variation of self-reported knee pain, function and quality of life with age and gender in the adult population and to establish population-based reference data for the Knee injury and Osteoarthritis Outcome Score (KOOS). METHODS: Population-based cohort retrieved from the national population register. The knee-specific Knee injury and Osteoarthritis Outcome Score (KOOS) was mailed to 840 subjects aged 18-84 yrs. RESULTS: 68% response rate. Women in the age group 55-74 reported more knee-related complaints in all the KOOS subscales than age-matched men. The differences were significant for the subscales Pain (p = 0.027), Symptoms (p = 0.003) and ADL function (p = 0.046). In men, worse ADL and Sport and Recreation function was seen in the oldest age group 75-84 years compared to the younger age groups (p < 0.030). In women, worse Pain (p < 0.007), ADL (p < 0.030), Sport and Recreation (p < 0.001) and QOL (p < 0.002) were seen already in the age group 55-74 compared to the younger age groups. CONCLUSION: We found pain and other symptoms, physical function, and knee-related quality of life to vary with age and gender implying the use of age- and gender matched reference values for improved understanding of the outcome after interventions due to knee injury and knee OA.

Arthroscopically assisted anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft without wound drainage: short- to middle-term outcome.

INTRODUCTION: Several studies have suggested that anterior cruciate ligament reconstruction (ACLR) without wound drainage has no impact on long-term follow-up. AIM: To investigate a prospective patient series as measured by the patient-administered disease-specific questionnaire Knee injury and Osteoarthritis Outcome Score (KOOS). MATERIAL AND METHODS: The study included 101 consecutive patients (71 men and 30 women) with a mean age of 30 years (SD 10, range: 15-62 years), who had undergone primary single incision arthroscopic bone-patellar tendon-bone autograft (BPTB) ACLR without wound drainage. All patients completed KOOS questionnaires, preoperatively and at a mean follow-up of 1.4 years (range: 0.4-3.4). Satisfactory clinical outcome (function recovery - FR) was defined as the lower threshold for the 95% CI of 18-34-year old males and corresponded to a KOOS score > 90 for Pain, 84 for Symptoms, 91 for Activities of Daily Living (ADL), 80 for Sports/Recreation, and 81 for Quality of Life (QOL). A non-satisfactory result was defined as treatment failure (TF) and corresponded to a QOL score < 44. RESULTS: All patients achieved 90° of knee flexion on the first postoperative day and full extension 2 weeks postoperatively. A full range of motion was achieved in less than 6 weeks postoperatively. No postoperative complications were reported. Score improvement at follow-up was observed in the KOOS subscales Pain, Symptoms and ADL. Criteria for FR were fulfilled by 52% of patients for Pain, 47% for Symptoms, 62% for ADL, 34% for Sports/Recreation and 15% for QOL, whereas criteria for TF were fulfilled by 29% of patients. CONCLUSIONS: The study demonstrated that the primary ACLRs without wound drainage did not have any negative impact for patient-reported recovery.

The effect of patient characteristics on variability in pain and function over two years in early knee osteoarthritis.

BACKGROUND: Large variations in pain and function are seen over time in subjects at risk for and with radiographic knee osteoarthritis (OA). We hypothesized that this variation may be related not only to knee OA but also to patient characteristics. The objective of this study was to investigate the influence of age, gender, and body mass index (BMI) on clinically relevant change in pain and function over two years in subjects at high risk for or with knee OA. METHODS: We assessed 143 individuals (16% women, mean age 50 years [range 27-83]) twice; 14 and 16 years after isolated meniscectomy. Subjects completed one disease-specific questionnaire, the Knee injury and Osteoarthritis Outcome Score (KOOS) and one generic measure, the SF-36. Individuals with a BMI between 25 and 29.9 were considered overweight, while individuals with a BMI of 30 or more were considered obese. RESULTS: Subjects aged 46-56 (the middle tertile) were more likely to change (> or =10 points on a 0-100 scale) in the KOOS subscale Activities of Daily Living (ADL) than younger subjects (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 1.5-13.0). Essentially the same result was obtained after adjusting for baseline values. Overweight or obesity was a risk factor for clinically relevant change for knee pain (OR 2.4, 95% CI 1.0-5.8, OR 4.0, 95% CI 1.2-13.6) and obesity for change in ADL (OR 4.3, 95% CI 1.2-15.4). The results did not remain significant when adjusted for the respective baseline value. Being symptomatic was strongly associated with increased variation in pain and function while presence or absence of radiographic changes did not influence change over two years in this cohort. CONCLUSION: In a population highly enriched in early-stage and established knee OA, symptomatic, middle-aged, and overweight or obese subjects were more likely to vary in their knee function and pain over two years. The natural course of knee pain and function may be associated with subject characteristics such as age and BMI.

Similar group mean scores, but large individual variations, in patient-relevant outcomes over 2 years in meniscectomized subjects with and without radiographic knee osteoarthritis.

BACKGROUND: Epidemiological studies have, so far, identified factors associated with increased risk for incident or progressive OA, such as age, sex, heredity, obesity, and joint injury. There is, however, a paucity of long-term data that provide information on the nature of disease progression on either group or individual levels. Such information is needed for identification of study cohorts and planning of clinical trials. The aim of the study was, thus, to assess the variation in pain and function on group and individual level over 2 years in previously meniscectomized individuals with and without radiographic knee osteoarthritis (OA). METHODS: 143 individuals (16% women, mean age at first assessment 50 years [range 27-83]) were assessed twice; approximately 14 and 16 years after isolated meniscectomy, with a median interval of 2.3 years (range 2.3-3.0). Radiographic OA (as assessed at the time of second evaluation) was present in the operated knee in 40%, and an additional 19% had a single osteophyte grade 1 in one or both of the tibiofemoral compartments. Subjects completed the self-administered and disease-specific Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: There were no significant changes in the group mean KOOS subscale scores over the 2-year period. However, a great variability over time was seen within individual subjects. Out of 143 subjects, 16% improved and 12% deteriorated in the subscale Pain, and 13% improved and 14% deteriorated in the subscale ADL > or = 10 points (the suggested threshold for minimal perceptible clinical change). Similar results were seen for remaining subscales. CONCLUSION: Group mean scores for this study cohort enriched in incipient and early-stage knee OA were similar over 2 years, but pain, function and quality of life changed considerably in individuals. These results may be valid also for other at risk groups with knee OA, and motivate further careful examination of the natural history of OA, as well as properties of the OA outcome instruments used. Longitudinal outcome data in OA studies need to be analyzed both on an individual and a group level.

Knee outcome scales: Basic concepts, review of methods, cross-cultural and linguistic adaptation.

In recent years, outcome assessment following different therapeutic procedures has increasingly focused on the patient's perspective. While traditional measures of outcome, including physical examination and imaging diagnostics of the knee are complementary, patient-relevant questionnaires have become more and more important in determining the value of therapeutic procedures. Therefore, there is a clear need for clinicians in all fields, especially orthopedics, to be familiar with the available scoring systems and their relative strengths and weaknesses. Several questionnaires are now available for active patients with knee disorders, as well as for older patients with degenerative conditions. We thus present knee rating scales, patient-reevant questionnaires, and generic measurement tools available for the assessment of patients with osteoarthritis following knee injury. These tools are described in detail and their relative merits are discussed. Since the reliability, validity and responsiveness of the knee scales are crucial for their use as outcome measures, these parameters are also described precisely. Along with the growing number of international, multi-cultural, and multilingual research projects, there is a need to adjust measurement tools to different conditions and circumstances. There is general agreement that a questionnaire, when adapted for use in a new country, should not only be translated precisely, but also adjusted culturally to maintain the content validity of the original version. The process of cross-cultural and linguistic adaptation includes initial translation, translation synthesis, back translation, review by an expert committee, testing of the pre-final version and, finally, the validation study. This procedure is described in detail.

Does concomitant meniscectomy affect medium-term outcome of anterior cruciate ligament reconstruction? A preliminary report.

INTRODUCTION: Anterior cruciate ligament (ACL) injury is often accompanied by injuries of the menisci. In order to restore knee stability, anterior cruciate ligament reconstruction (ACLR) is performed, with meniscus surgery when needed. The purpose of this study was to assess the medium-term outcome of ACLR in subjects with and without concomitant meniscus tear and partial meniscectomy. MATERIAL AND METHODS: We prospectively studied 73 patients after arthroscopically assisted bone-patellar tendon-bone ACLR. Subjects were divided into two subgroups: those who had only ACLR (group A, 54 subjects with mean age 28, (SD 9)) and those who underwent both ACLR and concomitant partial meniscectomy (group B, 19 subjects, mean age 32 [11]). Subjects completed a disease-specific questionnaire, the Knee injury and Osteoarthritis Outcome Score (KOOS), preoperatively and at a minimum follow-up of 1 year. RESULTS: No differences in mean scores between group A and B were observed either preoperatively or at follow-up. We found a significant change in mean score in the KOOS subscale QoL in group A following ACLR (Δ = 9 points, p = 0.039). Most subjects improved in the KOOS subscales Sports and Recreation and QoL in both group A (59 and 52% respectively) and B (63 and 47% respectively). Eight subjects (15%) from group A and 1 (5%) from group B fulfilled criteria of functional recovery. Criteria of treatment failure were fulfilled in 17 subjects (32%) from A and 4 (21%) from group B. CONCLUSIONS: Patients undergoing ACLR with partial meniscectomy had a similar medium-term outcome compared to individuals with ACL tear alone.

Relevance of infiltration analgesia in pain relief after total knee arthroplasty.

OBJECTIVE: The aim of the study was to assess the effect of different types of anesthesia on pain intensity in early postoperative period. PATIENTS AND METHODS: A total of 87 patients (77 women, 10 men) scheduled for total knee arthroplasty (TKA) were assigned to receive either subarachnoid anesthesia alone or in combination with local soft tissue anesthesia, local soft tissue anesthesia and femoral nerve block and pre-emptive infiltration together with local soft tissue anesthesia. We assessed the pain intensity, opioid consumption, knee joint mobility, and complications of surgery. RESULTS: Subjects with pre-emptive infiltration and local soft tissue anesthesia had lower pain intensity on the first postoperative day compared to those with soft tissue anesthesia and femoral nerve block (P=0.012, effect size 0.68). Subjects who received pre-emptive infiltration and local soft-tissue anesthesia had the greatest range of motion in the operated knee at discharge (mean 90 grades [SD 7], P=0.01 compared to those who received subarachnoid anesthesia alone, and P=0.001 compared to those with subarachnoid together with soft tissue anesthesia). CONCLUSION: Despite the differences in postoperative pain and knee mobility, the results obtained throughout the postoperative period do not enable us to favour neither local nor regional infiltration anesthesia in TKA. Level of Evidence II, Prospective Comparative Study.