Topical Cannabidiol (CBD) After Total Knee Arthroplasty Does Not Decrease Pain or Opioid Use: A Prospective Randomized Double-Blinded Placebo-Controlled Trial.

BACKGROUND: Multimodal analgesia has become the standard of care for pain management following total knee arthroplasty (TKA). Cannabidiol (CBD) is increasingly utilized in the postoperative period. The purpose of this study was to analyze the analgesic benefits of topical CBD following primary TKA. METHODS: In this randomized double-blinded placebo-controlled trial, 80 patients undergoing primary unilateral TKA applied topical CBD (CBD; n = 19), essential oil (EO; n = 21), CBD and essential oil (CBD + EO; n = 21), or placebo (PLA; n = 19) thrice daily around the knee for two weeks postoperatively. This supplemented a standardized multimodal analgesic protocol. Outcomes included visual analog scale (VAS) pain and numeric rating scale (NRS) sleep scores (collected on postoperative day [POD] 0, 1, 2, 7, 14, 42), and cumulative postoperative opioid use (42 days). RESULTS: Demographic characteristics were similar among the four cohorts. Preoperative VAS and NRS scores were similar among groups. The CBD cohort had a higher mean VAS pain score on POD 2 compared to the EO cohort (CBD: 69.9 ± 19.3 versus. EO: 51.0 ± 18.2; P = .013). No statistically significant differences existed for VAS scores at other times, and no statistically significant differences were observed for postoperative NRS sleep scores or postoperative opioid use at any time point. CONCLUSION: Utilization of topical CBD in supplement to multimodal analgesia did not reduce pain or opioid consumption, or improve sleep scores following TKA. These results suggest that the local effects of topical CBD are not beneficial for providing additional pain relief after TKA.

Stress and Strain During Total Joint Arthroplasty Are Not Impacted by Hand Dominance or Operative Laterality in Orthopedic Surgeons.

BACKGROUND: Orthopedic surgeons experience significant musculoskeletal pain and work-related injuries while performing total joint arthroplasty (TJA). We sought to investigate the impact of operative extremity and surgeon limb dominance on surgeon physiologic stress and energy expenditure during TJA. METHODS: This was a prospective cohort study conducted at a tertiary academic practice. Cardiorespiratory data was recorded continuously in 3 high-volume arthroplasty surgeons using a smart garment that measured heart rate (HR), HR variability, respiratory rate, minute ventilation, and energy expenditure (calories) during conventional total knee (TKA) and total hip arthroplasty (THA). RESULTS: Surgeon 1 and 2 (right-handed) performed 21 right TKAs, 10 left TKAs, 13 right THAs, and 10 left THAs. Surgeon 3 (left-handed) performed 6 right TKAs, 9 left TKAs, 16 right THAs, and 10 left THAs. While performing TKA or THA, limb laterality had no significant impact on operative time and no significant differences existed in HR, HR variability, respiratory rate, minute ventilation, or energy expenditure for any right-handed or left-handed surgeons, regardless of the operative limb laterality. While performing TKA, consistently standing on the side of hand dominance was associated with decreased strain and stress, compared to always standing on the operative side. CONCLUSION: This study suggests that surgeon hand dominance and operative limb laterality do not impact energy expenditure or physiologic strain during TJA. However, consistently standing on the side of hand dominance in TKA may lead to decreased physiologic strain and stress during surgery. Further study utilizing wearable technology during TJA may provide orthopedic surgeons with information about modifiable factors that contribute to differences in physiological parameters during surgery.

Are Patients With End-Stage Arthritis Willing to Delay Arthroplasty for Payer-Mandated Physical Therapy?

BACKGROUND: Payer coverage policies have recently begun requiring physical therapy (PT) prior to total hip arthroplasty and total knee arthroplasty (TKA). It remains controversial if such a mandate is appropriate for patients with end-stage, symptomatic osteoarthritis. The purpose of this study is to assess if such patients are amenable to delaying surgery for a trial of PT. METHODS: All patients scheduled for elective primary total hip arthroplasty and TKA in a 3-month period by 1 of 7 surgeons at a single institution were contacted and asked to participate in a survey. Participation in PT within the prior 6 months was noted. Patients were asked if they would be willing to delay surgery for a PT trial as a nonsurgical option to improve their symptoms. The primary reason for their answer was also recorded. RESULTS: In total, 200 patients were successfully contacted and agreed to participate. The mean age was 66 years, 47% were male, the mean body mass index was 31 kg/m2, and 66% were scheduled for TKA. In total, 157 patients (79%) stated they had not done PT in the preceding 6 months, and 185 patients (93%) stated they would not want to delay surgery for mandatory PT. The most common reasons for refusing PT were "surgery is inevitable" (44%) and "unlikely to improve pain" (29%). CONCLUSION: Patients with end-stage hip and knee osteoarthritis who are otherwise candidates for surgery appear overwhelmingly opposed to mandatory preoperative PT, mostly due to a lack of perceived efficacy in providing long-term symptom relief compared to total joint arhtroplasty.

Cumulative Intraarticular Injections Are Not a Risk Factor for Periprosthetic Joint Infection Following total Knee Arthroplasty.

BACKGROUND: While injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA. METHODS: This retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections. RESULTS: 648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI. DISCUSSION: A cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.

Surgeons Experience Greater Cardiorespiratory Strain and Stress During Total Hip Arthroplasty Than Total Knee Arthroplasty.

BACKGROUND: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are physically demanding, with a high prevalence of work-related injuries among arthroplasty surgeons. It is unknown whether there are differences in cardiorespiratory output for surgeons while performing THA and TKA. The objective of this study is to characterize whether differences in surgeon physiological response exist while performing primary THA vs TKA. METHODS: This is a prospective cohort study including 3 high-volume, fellowship-trained arthroplasty surgeons who wore a smart garment that recorded cardiorespiratory data on operative days during which they were performing primary conventional TKA and THA. Variables collected included patient body mass index (BMI), operative time (minutes), heart rate, heart rate variability, respiratory rate, minute ventilation, and energy expenditure (calories). RESULTS: Seventy-six consecutive cases (49 THAs and 27 TKAs) were studied. Patient BMI was similar between the 2 cohorts (P > .05), while operative time was significantly longer in TKAs (60.4 ± 12.0 vs 53.6 ± 11.8; P = .029). During THA, surgeons had a significantly higher heart rate (95.7 ± 9.1 vs 90.2 ± 8.9; P = .012), energy expenditure per minute (4.6 ± 1.23 vs 3.8 ± 1.2; P = .007), and minute ventilation (19.0 ± 3.0 vs 15.5 ± 3.3; P < .001) compared to TKA. CONCLUSION: Surgeons experience significantly higher physiological strain and stress while performing THA. While scheduling THAs and TKAs, surgeons should consider the higher physical demand associated with THAs and ensure adequate personal preparation and sequence of cases.