RESUMEN
Purpose: This study was performed to investigate the relationship between the amount of femorotibial alignment correction and the amount of improvement of hindfoot alignment in total knee arthroplasty (TKA). Methods: A total of 159 knees undergoing TKA in 120 patients were assessed preoperatively and at 2 weeks, 1 month, 3 months and 6 months postoperatively. Standing hindfoot alignment was evaluated using the leg-heel angle (LHA). The amount of change in hindfoot alignment was compared between patients with severe varus knee (Group 1) and those with moderate varus, neutral or valgus knee (Group 2). Results: The mean values of pre- and postoperative hip-knee-ankle (HKA) angle were -14 ± 4° and -1 ± 3° in Group 1 and -7 ± 5° and -1 ± 3° in Group 2, respectively. The differences between pre- and postoperative LHA were significantly larger in Group 1 than in Group 2 at 2 weeks, 1 month and 3 months postoperatively (p = 0.006, 0.001 and 0.03, respectively). At 6 months postoperatively, no differences were observed between the two groups (p = 0.31). Conclusion: The amount of change in hindfoot alignment was larger in Group 1 than in Group 2 at 2 weeks, 1 month and 3 months after TKA, but there was no significant difference between the two groups at 6 months after TKA. Level of Evidence: Prognostic Level II.
RESUMEN
INTRODUCTION: The purpose of this study was to examine the comparative precision of the augmented reality (AR)-assisted navigation system and the accelerometer-based navigation system in total knee arthroplasty (TKA). MATERIALS AND METHODS: We performed noninferiority analysis in a retrospective cohort. The coronal alignment of femoral prosthesis was compared between 109 TKAs performed using the AR-assisted navigation system and 118 TKAs performed using the accelerometer-based navigation system. All femoral prostheses were planned to be positioned perpendicular to the mechanical axis of the femur. The primary outcome was the success rate of coronal alignment of the femoral prosthesis defined as alignment error relative to neutral alignment <3°. We calculated the noninferiority margin as 7%-points using the 95%-95 % method and also confirmed the validity of the noninferiority margin using the fixed margin method. Noninferiority would be shown if the lower boundary of the 95 % confidence interval (CI) for the between-group difference in percentage of the success rate was not less than 0.93 (i.e., 1.00 - 0.07). RESULTS: Treatment success was achieved in 104 of 109 patients (95.4 %) in the AR-assisted navigation group and 110 of 118 (93.2 %) in the accelerometer-based navigation group. The risk ratio of success between the AR-assisted navigation group versus accelerometer-based navigation group was 1.02 (95 % CI, 0.96 to 1.09): the CIs did not include the noninferiority margin of 0.93. CONCLUSION: The AR-assisted navigation system was noninferior to the accelerometer-based navigation system in terms of coronal alignment of the femoral prosthesis in TKA.
RESUMEN
BACKGROUND: Previous studies reported good outcomes of acetabular cup placement using portable navigation systems during THA. However, we are aware of no prospective studies comparing inexpensive portable navigation systems using augmented reality (AR) technology with accelerometer-based portable navigation systems in THA. QUESTIONS/PURPOSES: (1) Is the placement accuracy of the acetabular cup using the AR-based portable navigation system superior to that of an accelerometer-based portable navigation system? (2) Do the frequencies of surgical complications differ between the two groups? METHODS: We conducted a prospective, two-arm, parallel-group, randomized controlled trial involving patients scheduled for unilateral THA. Between August and December 2021, we treated 148 patients who had a diagnosis of osteoarthritis, idiopathic osteonecrosis, rheumatoid arthritis, or femoral neck fracture and were scheduled to undergo unilateral primary THA. Of these patients, 100% (148) were eligible, 90% (133) were approached for inclusion in the study, and 85% (126) were finally randomized into either the AR group (62 patients) or the accelerometer group (64 patients). An intention-to-treat analysis was performed, and there was no crossover between groups and no dropouts; all patients in both groups were included in the analysis. There were no differences in any key covariates, including age, sex, and BMI, between the two groups. All THAs were performed via the modified Watson-Jones approach with the patient in the lateral decubitus position. The primary outcome was the absolute difference between the cup placement angle displayed on the screen of the navigation system and that measured on postoperative radiographs. The secondary outcome was intraoperative or postoperative complications recorded during the study period for the two portable navigation systems. RESULTS: There were no differences between the AR and accelerometer groups in terms of the mean absolute difference in radiographic inclination angle (3° ± 2° versus 3° ± 2° [95% CI -1.2° to 0.3°]; p = 0.22). The mean absolute difference in radiographic anteversion angle displayed on the navigation screen during surgery compared with that measured on postoperative radiographs was smaller in the AR group than that in the accelerometer group (2° ± 2° versus 5° ± 4° [95% CI -4.2° to -2.0°]; p < 0.001). There were few complications in either group. In the AR group, there was one patient each with a surgical site infection, intraoperative fracture, distal deep vein thrombosis, and intraoperative pin loosening; in the accelerometer group, there was one patient each with an intraoperative fracture and intraoperative loosening of pins. CONCLUSION: Although the AR-based portable navigation system demonstrated slight improvements in radiographic anteversion of cup placement compared with the accelerometer-based portable navigation system in THA, whether those small differences will prove clinically important is unknown. Until or unless future studies demonstrate clinical advantages that patients can perceive that are associated with such small radiographic differences, because of the costs and the unquantified risks associated with novel devices, we recommend against the widespread use of these systems in clinical practice. LEVEL OF EVIDENCE: Level I, therapeutic study.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Realidad Aumentada , Prótesis de Cadera , Cirugía Asistida por Computador , Humanos , Artroplastia de Reemplazo de Cadera/efectos adversos , Acetábulo/diagnóstico por imagen , Acetábulo/cirugía , Cirugía Asistida por Computador/efectos adversos , AcelerometríaRESUMEN
This study was performed to examine the hypothesis that the rate of allogeneic blood transfusion in patients who did not predeposit an autologous blood transfusion before single-anesthetic bilateral total knee arthroplasty (TKA) would be noninferior to that in patients who did predeposit blood. Methods: We assessed the number of allogeneic transfusions required in 338 patients undergoing single-anesthetic bilateral TKA with a preoperative hemoglobin level of ≥11.0 g/dL. All TKAs were performed by a single surgeon according to the same operative and postoperative protocol. All patients received a combination of intravenous and intra-articular tranexamic acid. Neither a pneumonic tourniquet nor a drain was used. The difference in the risk of allogeneic transfusion between patients without and with autologous blood predeposit was compared with a noninferiority margin of 10 percentage points. Results: Allogeneic transfusion was required in 1 (0.5%) of 194 patients who predeposited autologous blood and 3 (2.1%) of 144 patients who did not predeposit blood. The difference in risk was -1.6 percentage points (95% confidence interval, -4.1 to 1.0 percentage points); the confidence interval did not include the noninferiority margin and included zero. Conclusions: In single-anesthetic bilateral TKA, allogeneic transfusion requirements in patients who did not predeposit autologous blood were noninferior to those in patients who predeposited blood. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
RESUMEN
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.
RESUMEN
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.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Realidad Aumentada , Prótesis de Cadera , Cirugía Asistida por Computador , Acelerometría , Acetábulo/diagnóstico por imagen , Acetábulo/cirugía , Humanos , Estudios RetrospectivosRESUMEN
This open-label, multicenter, prospective, randomized controlled trial aimed to determine the effectiveness of esflurbiprofen plaster (SFPP) and flurbiprofen tablets (FPTs) on knee osteoarthritis in patients scheduled for total knee arthroplasty by comparing the transfer of esflurbiprofen and flurbiprofen to tissues and fluids. Thirty-eight patients were randomly assigned in a 1:1 ratio to receive SFPP or FPT. Both groups were then divided into four subgroups, according to whether they received the final dose of SFPP or FPT at 2, 7, 12, or 24 h before planned surgery. The primary endpoints were the esflurbiprofen concentrations in synovium, synovial fluid, and plasma. Areas under concentration-time curves (AUC0-24 h ) of esflurbiprofen were calculated for each group. Pain was assessed using a numeric rating scale (NRS) 7 days before and immediately before surgery. The AUC0-24 h in the synovium were 4401.24 and 4862.70 ng·h/g in the SFPP and FPT groups, respectively. Maximum esflurbiprofen concentrations were observed in the synovium, synovial fluids, and plasma after SFPP application for 12 h. The NRS results indicated a long-lasting effect of SFPP. The AUC of the synovial esflurbiprofen concentration of SFPP indicated that the SFPP is transferred to the synovium and synovial fluid in high concentration. The efficient deep-tissue transfer of esflurbiprofen suggests that its pharmacokinetic characteristics differ from those of conventional topical NSAIDs. This study was prospectively registered in the Japan Registry of Clinical Trials (registration number: jRCTs031180228).
Asunto(s)
Flurbiprofeno , Osteoartritis de la Rodilla , Antiinflamatorios no Esteroideos , Humanos , Osteoartritis de la Rodilla/tratamiento farmacológico , Osteoartritis de la Rodilla/cirugía , Estudios Prospectivos , ComprimidosRESUMEN
An augmented reality (AR)-based navigation system allows visualization of the center of the femoral head and femoral mechanical axis superimposed on the surgical field during total knee arthroplasty (TKA) and may help surgeons to improve the accuracy of distal femoral resection. METHODS: First, we resected 10 femoral Sawbones specimens using the AR-based navigation system and performed computed tomography (CT) to measure the resection angle of the distal part of the femur. We calculated the absolute values of the differences between angles measured using CT images and angles displayed on the smartphone screen of the navigation system. Second, we measured coronal alignment using standing long-leg radiographs for 72 patients undergoing TKA and compared the error in the resection angle between TKA using the AR-based navigation system and that using a conventional intramedullary guide. RESULTS: In the experimental study, the absolute values of the differences between angles measured on CT images and angles displayed using the AR-based navigation system were 0.8° ± 0.5° (range, 0.3° to 1.9°) in the coronal plane and 0.6° ± 0.5° (range, 0.0° to 1.4°) in the sagittal plane. In the clinical study, the mean absolute value of the error in coronal alignment was significantly smaller in the AR-based navigation group than the intramedullary-guide group (1.1° ± 1.0° [range, 0.0° to 3.2°] compared with 2.2° ± 1.6° [range, 0.0° to 5.5°], respectively; 95% confidence interval, 0.5° to 1.8°; p < 0.001). CONCLUSIONS: The AR-based navigation system may enable surgeons to perform distal femoral resection more accurately than with the conventional intramedullary guide during TKA. CLINICAL RELEVANCE: This study validates the use of AR technology to enhance the precision of bone resection in TKA.
RESUMEN
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.
Asunto(s)
Corticoesteroides/uso terapéutico , Artroplastia de Reemplazo de Cadera , Dolor Postoperatorio/prevención & control , Anciano , Anestesia General , Método Doble Ciego , Femenino , Humanos , Inyecciones Intraarticulares , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Estudios ProspectivosRESUMEN
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.
Asunto(s)
Antifibrinolíticos/administración & dosificación , Artroplastia de Reemplazo de Rodilla , Pérdida de Sangre Quirúrgica/prevención & control , Ácido Tranexámico/administración & dosificación , Administración Intravenosa , Anciano , Método Doble Ciego , Femenino , Humanos , Inyecciones Intraarticulares , Análisis de Intención de Tratar , MasculinoRESUMEN
BACKGROUND: No randomized controlled trial has investigated a more optimal timing of periarticular injection for pain relief after total hip arthroplasty. METHODS: The study included 140 patients, and these patients were randomly allocated to the early-stage (periarticular injection was performed just before arthrotomy, and placebo was injected after implantation) or late-stage (placebo was injected just before arthrotomy, and periarticular injection was performed after implantation) injection groups. Other perioperative interventions were similar in all participants. The prespecified primary outcome was postoperative pain score at the recovery room. RESULTS: The visual analog scale score at the recovery room of the early-stage injection group was significantly lower than that of the late-stage injection group (30 ± 28 vs 46 ± 30 mm; 95% CI, -25 to -5 mm; P = .0022), and this difference reaches a minimal clinically important difference level of 10 mm. No differences were observed with regard to complication rate. CONCLUSION: Early-stage periarticular injection during total hip arthroplasty provided better postoperative pain relief than late-stage periarticular injection without elevating complication rate. LEVEL OF EVIDENCE: Level I, randomized controlled trial.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Anestésicos Locales/uso terapéutico , Artroplastia de Reemplazo de Cadera/efectos adversos , Método Doble Ciego , Humanos , Inyecciones Intraarticulares , Manejo del Dolor , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Estudios ProspectivosRESUMEN
BACKGROUND: We developed an augmented reality (AR)-based portable navigation system in which the surgeon can view the pelvic plane and placement angle of an acetabular cup on the display of a smartphone during THA. QUESTIONS/PURPOSES: (1) Is acetabular component placement more accurate using the AR-based portable navigation system compared with the conventional freehand technique? (2) Is intraoperative measurement of placement angle more accurate when using the AR-based portable navigation system compared with a goniometer? METHODS: Forty-six patients were randomly assigned to undergo acetabular cup placement during THA using the AR-based portable navigation system (AR navigation group) or placement of a mechanical alignment guide (conventional group). All surgeries were performed with the patient in the lateral decubitus position. We compared the absolute value of the difference between the targeted placement angle and postoperative measured placement angle between the groups using two types of imaging (radiography and CT). RESULTS: In terms of radiographic inclination, the mean differences between the targeted placement angle and postoperative measured angle were smaller in the AR navigation group than in the conventional group for both radiographs and CT images (2.3° ± 1.4° versus 3.9° ± 2.4°, respectively; p = 0.009 and 1.9° ± 1.3° versus 3.4° ± 2.6°, respectively; p = 0.02). There were no differences in radiographic anteversion between the two groups. No complications were associated with the use of the AR-based portable navigation system. CONCLUSIONS: This system yielded no differences in acetabular anteversion accuracy, and no clinically important differences in acetabular inclination. Therefore, at this time we cannot recommend this device as its costs and risks cannot be justified based on the absence of a clinically meaningful difference in cup placement accuracy. Although we detected no complications, this was a small series, and this approach adds both surgical time and pins in the ilium. LEVEL OF EVIDENCE: Level I, therapeutic study.
Asunto(s)
Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera/métodos , Realidad Aumentada , Articulación de la Cadera/cirugía , Prótesis de Cadera , Cirugía Asistida por Computador/métodos , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/instrumentación , Femenino , Necrosis de la Cabeza Femoral/cirugía , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/cirugía , Posicionamiento del Paciente , Cirugía Asistida por Computador/instrumentación , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Artrometría Articular/métodos , Artroplastia de Reemplazo de Rodilla/métodos , Inestabilidad de la Articulación/prevención & control , Monitoreo Intraoperatorio/métodos , Osteoartritis de la Rodilla/cirugía , Rango del Movimiento Articular/fisiología , Anciano , Anciano de 80 o más Años , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Japón , Prótesis de la Rodilla , Masculino , Análisis Multivariante , Osteoartritis de la Rodilla/diagnóstico por imagen , Complicaciones Posoperatorias/fisiopatología , Complicaciones Posoperatorias/prevención & control , Diseño de Prótesis , Análisis de Regresión , Resultado del TratamientoRESUMEN
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.
RESUMEN
Although continuing antithrombotic therapy is desirable to prevent perioperative cardiovascular and cerebrovascular diseases, perioperative blood loss remains a concern in patients undergoing total knee arthroplasty. The purpose of this study was to assess the impact of continuing chronic antithrombotic therapy on blood loss and major bleeding events. METHODS: We classified 201 consecutive patients undergoing total knee arthroplasty into 2 groups: (1) patients taking antiplatelet agents, vitamin K antagonists, and/or direct oral anticoagulants, referred to as the continuing antithrombotic therapy group (n = 32); and (2) patients not receiving these agents, referred to as the no antithrombotic therapy group (n = 169). During the study period, antithrombotic agents were continued perioperatively in all patients receiving antithrombotic therapy. Surgical procedures were performed without the use of a pneumatic tourniquet or drain. Screening for deep vein thrombosis was routinely performed before and after total knee arthroplasty. The total perioperative blood loss was calculated from blood volume and change in hemoglobin from preoperatively to postoperative days 1, 3, and 7. RESULTS: The perioperative blood loss after total knee arthroplasty did not differ significantly between the continuing antithrombotic therapy group and the no antithrombotic therapy group at 1 day postoperatively (448 ± 213 compared with 495 ± 345 mL [95% confidence interval (CI) of the difference, -172 to 77 mL]; p = 0.45), 3 days postoperatively (841 ± 308 compared with 826 ± 328 mL [95% CI, -108 to 139 mL]; p = 0.81), and 7 days postoperatively (855 ± 313 compared with 861 ± 245 mL [95% CI, -122 to 108 mL]; p = 0.91). No patients in the continuing antithrombotic therapy group and 2 patients (1.2%) in the no antithrombotic therapy group had allogeneic blood transfusion (p = 1). No major bleeding events occurred in the continuing antithrombotic therapy group. CONCLUSIONS: Perioperative blood loss in patients continuing chronic antithrombotic therapy during total knee arthroplasty was not significantly different from that in patients receiving no chronic antithrombotic therapy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
RESUMEN
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.
Asunto(s)
Osteoartritis de la Rodilla/tratamiento farmacológico , Ácido Tranexámico/administración & dosificación , Administración Intravenosa , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Rodilla , Quimioterapia Adyuvante , Método Doble Ciego , Femenino , Humanos , Inyecciones Intraarticulares , MasculinoRESUMEN
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.
Asunto(s)
Anestésicos Locales/administración & dosificación , Artroplastia de Reemplazo de Rodilla , Inyecciones Intraarticulares , Dolor Postoperatorio/tratamiento farmacológico , Anciano , Analgésicos/administración & dosificación , Anestesia General , Esquema de Medicación , Epinefrina/administración & dosificación , Femenino , Humanos , Cetoprofeno/administración & dosificación , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Estudios Prospectivos , Ropivacaína/administración & dosificación , Resultado del TratamientoRESUMEN
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.
Asunto(s)
Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Procedimientos Quirúrgicos Dermatologicos/efectos adversos , Procedimientos Quirúrgicos Dermatologicos/métodos , Hipoestesia/etiología , Herida Quirúrgica/complicaciones , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Articulación de la Rodilla/cirugía , Masculino , Postura , Estudios Prospectivos , Rango del Movimiento ArticularRESUMEN
BACKGROUND: Periarticular analgesic injection (PAI) is being used more commonly for pain relief after orthopaedic surgeries. However, there is conflicting evidence regarding the effectiveness of PAI for post-THA pain relief. QUESTIONS/PURPOSES: In a double-blind, randomized, controlled trial among patients undergoing same-day bilateral THA, with each patient serving as his or her own control, we asked: (1) Did the pain score as measured on a 100-mm VAS differ between the hips that received PAI versus placebo? (2) Were there differences in complications between the treatment and control hips in these patients? METHODS: Over a 1-year period at one center, 45 patients underwent same-day bilateral THA; three were excluded for prespecified reasons, and two declined participation in this randomized, controlled trial, leaving 40 patients (80 THAs) in the study. Patients randomly received PAI in one hip and placebo in the contralateral hip; patients, surgeons, and nurses were blinded in terms of which hip received the PAI and which hip received a placebo saline injection. The PAI solution included ropivacaine, morphine hydrochloride hydrate, methylprednisolone, ketoprofen, and epinephrine. The primary outcome was the VAS for pain at rest 24 hours after THA, measured using a 100-mm horizontal VAS. The VAS score was compared between two groups and assessed to reach the reported threshold values for the minimum clinically important difference (MCID) of 20 mm for the postoperative VAS score. No patients were lost to followup, and there were no missing data for the primary outcome. Complications that occurred during the trial were recorded prospectively with emphasis on infection, wound complications, nerve palsy and allergic reactions to the injections. RESULTS: There were no clinically important differences between hips treated with the PAI and those treated with the placebo injection at any point. The hips that received PAI had less pain than those receiving placebo 24 hours after THA (16 ± 17 mm versus 22 ± 20 mm; mean difference, 6 mm; 95% confidence interval [CI], 2-9 mm; p = 0.006), but this effect size was below the MCID of 20 mm and thus is unlikely to be clinically important. The hips that received PAI also had better VAS scores in the recovery room (38 ± 29 mm versus 52 ± 33 mm; mean difference 14 mm; 95% CI, 5-23 mm; p = 0.004) and 3 hours after THA than placebo controls (28 ± 22 mm versus 37 ± 24 mm; mean difference 9 mm; 95% CI, 2-16 mm; p = 0.010). Neither of these differences exceeded the MCID and likewise were unlikely to be clinically important. No complications, including surgical site infections, were observed in either group. CONCLUSIONS: Periarticular analgesic injection for pain control after THA did not result in a clinically important reduction in pain at any point examined. Given the expense associated with this PAI mixture and the lack of effectiveness outside this timeframe, we cannot recommend its use. Other mixtures or concentrations of drugs may be helpful in short-stay admissions for THA, but this will require further research. LEVEL OF EVIDENCE: Level I, therapeutic study.
Asunto(s)
Analgésicos/administración & dosificación , Artroplastia de Reemplazo de Cadera/efectos adversos , Articulación de la Cadera/cirugía , Diferencia Mínima Clínicamente Importante , Dolor Postoperatorio/prevención & control , Anciano , Analgésicos/efectos adversos , Método Doble Ciego , Combinación de Medicamentos , Epinefrina/administración & dosificación , Femenino , Humanos , Inyecciones Intraarticulares , Japón , Cetoprofeno/administración & dosificación , Masculino , Metilprednisolona/administración & dosificación , Persona de Mediana Edad , Morfina/administración & dosificación , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/etiología , Efecto Placebo , Estudios Prospectivos , Ropivacaína/administración & dosificación , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background. Although active ankle movement plays a predominant role in mechanical thromboprophylaxis following total hip arthroplasty (THA), the most effective frequency of movement remains unclear. Materials and Methods. In 29 consecutive patients undergoing THA, the velocity of blood flow in the profunda femoris was measured after various frequencies of ankle movement two days after THA using a pulse wave Doppler ultrasound system. To test the interobserver reliabilities for the velocity measured with Doppler ultrasound system, the intraclass correlation coefficient was calculated based on the measurement in 10 limbs of healthy volunteers. Results. At 0, 1, and 2 minutes after ankle movement, the velocity after movement at 60 contractions per minute was significantly faster than that after movement at 40 or 80 contractions per minute (p = 0.0007, repeated-measures analysis of variance). The intraclass correlation coefficient score in two investigators was 0.849 (95% confidence interval, 0.428 to 0.962). Conclusions. Active ankle movement at 60 contractions per minute is recommended in patients receiving THA to obtain optimal venous blood flow.