Ultrasound-guided suprainguinal fascia iliaca compartment block and early postoperative analgesia after total hip arthroplasty: a randomised controlled trial.

BACKGROUND: Hip replacement surgery can be painful; postoperative analgesia is crucial for comfort and to facilitate recovery. Regional anaesthesia can reduce pain and postoperative opioid requirements. The role of ultrasound-guided suprainguinal fascia iliaca block for analgesia after elective total hip arthroplasty is not well defined. This randomised trial evaluated its analgesic efficacy. METHODS: Consenting participants (134) scheduled for elective primary total hip arthroplasty under spinal anaesthesia were randomly allocated to receive ultrasound-guided fascia iliaca block with ropivacaine 0.5% or sham block with saline. The primary outcome was opioid consumption in the first 24 h after surgery. Additional outcomes included pain scores at 4, 8, 12, and 16 h, opioid-related side-effects (nausea, vomiting, pruritis), ability to perform physiotherapy on the first postoperative day, and physiotherapist-assessed quadriceps weakness. RESULTS: There were no significant differences in 24-h opioid consumption (block vs sham block, mean difference -3.2 mg oral morphine equivalent, 95% confidence interval -15.3 to 8.1 mg oral morphine equivalent, P=0.55) or any other prespecified outcomes. CONCLUSIONS: In patients undergoing primary total hip arthroplasty, ultrasound-guided suprainguinal fascia iliaca block with ropivacaine did not confer a significant opioid-sparing effect compared with sham block. There were no differences in other secondary outcomes including pain scores, opioid-related side-effects, or ability to perform physiotherapy on the first postoperative day. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov (NCT03069183).

Extensive Proximal Extensor Mechanism Realignment for Chronic Patella Dislocations in Revision Knee Arthroplasty: Surgical Technique.

Patella dislocation after primary or revision total knee arthroplasty (TKA) is a major challenge in revision surgery. In practice, the main reason for patella maltracking and instability following TKA is malrotation of the femoral and/or tibial components. A number of soft tissue procedures, once component malrotation is corrected, have been described including proximal realignment, quadricepsplasty and distal realignment of patellar tendon with tibial tubercle osteotomy. Here, we describe our modified surgical technique in managing chronically dislocated patellae in knee arthroplasty which comprises of extensive lateral releases, vastus medialis obliquus (VMO) advancement and soft tissue reconstruction of the extensor mechanism with accompanying three case presentations achieving satisfactory clinical outcomes.

Catastrophic Polyethylene Failure and Fractured Femoral Component in Modern Knee Arthroplasty Design: A Case Report.

CASE: We report a 67-year-old gentleman who presented with a painful unstable knee. He had undergone a successful total knee arthroplasty 12 years earlier and was highly functional. He presented with a 10-month history of mild pain, instability, and gait alteration. During revision surgery, there was a loss of bony support, and a fractured femoral component was identified. He required constrained revision components for reconstruction and made an uneventful recovery. CONCLUSIONS: Fractured femoral components are rare complications of modern primary total knee arthroplasty. Loss of bony support in critical areas of high loading will inevitably lead to catastrophic component failure.

Overview of Randomized Controlled Trials in Total Knee Arthroplasty (47,675 Patients): What Have We Learnt?

BACKGROUND: The aim of this study is to provide an overview of randomized controlled trials (RCTs) in primary total knee arthroplasty summarizing the available high-quality evidence. METHODS: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2019, Issue 3), Ovid MEDLINE, and Embase. We excluded nonrandomized trials, trials on unicompartmental knee arthroplasty or revision surgery, systematic reviews, and meta-analyses. Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to the intervention groups (surgical approach, tourniquet use, design, etc.). RESULTS: Four hundred and three RCTs met the inclusion criteria and were included. The total number of patients in those 403 RCTs was 47,675. Only 33 RCTs (8.2%) reported significant differences between the intervention and the control groups. The trials were grouped into surgical approach 34, tourniquet 31, minimally invasive surgery 13, patient specific instrumentation 30, knee design 37, fixation 27, mobile bearing 47, navigation 50, polyethylene 19, technique 27, patella resurfacing 26, drain 19, closure 16, and others 27 RCTs. CONCLUSION: For the vast majority of patients, a standard conventional total knee arthroplasty with a surgical approach familiar to the surgeon using standard well-established components, with or without tourniquet, without surgical drain leads to satisfactory long-term clinical outcomes.

Extensor mechanism reconstruction "Tubeplasty" in total knee arthroplasty with previous patellectomy: Surgical technique and clinical outcomes.

PURPOSE: to evaluate our consecutive series of tubeplasty and extensor mechanism reconstruction during knee arthroplasty in patients with previous patellectomy. METHODS: we describe our surgical technique and present a retrospective consecutive series of 4 patients with a minimum 6 months follow-up. Knee society score (KSS), clinical and radiographic outcomes were collected at final follow up. RESULTS: we included 4 patients (2 males/2 females) with average age 65.5 years (range 58-76). There were 2 primary and 2 revision knee arthroplasties. The follow up ranged from 0.5 to 13 years. All 4 patients regained function and satisfactory clinical outcomes with KSS score 84.7 (range 79-90). CONCLUSION: satisfactory clinical outcomes can be achieved with extensor mechanism reconstruction and tubeplasty in patients with previous patellectomy undergoing primary and revision knee arthroplasty. LEVEL OF EVIDENCE: IV.

myHip&Knee: Improving Patient Engagement and Self-Management Through Mobile Technology.

Given the increasing volume of hip and knee replacement surgery with reduced hospital stays and resources, we explored technology to address gaps in patient care and enhance self-management. The team at the Holland Orthopaedic and Arthritic Centre of Sunnybrook Health Sciences Centre, which performs a high volume of joint replacement surgery, partnered with patients and a health technology company to create a mobile app: myHip&Knee. The results to date demonstrate that the app improves patient experience and reduces follow-up calls to surgeons' offices, ultimately reducing demand on healthcare resources. Early engagement of privacy and legal services, close patient and family collaboration and a well-developed evaluation strategy represent critical steps to successful development.

A Phase IV Study of Thromboembolic and Bleeding Events Following Hip and Knee Arthroplasty Using Oral Factor Xa Inhibitor.

BACKGROUND: Multiple randomized controlled trials have documented the effectiveness of rivaroxaban in the prevention of venous thromboembolism up to 1-month following total joint arthroplasty. However, the effectiveness and safety of rivaroxaban in the real-world setting, outside of the strict protocols used by randomized clinical trials, are unknown. METHODS: This was a prospective, observational, noninterventional, phase IV study of 3914 consecutive patients who underwent total joint arthroplasty from June 2010 to December 2012. Patients were treated with rivaroxaban 10 mg by mouth daily starting postoperative day 1 and continued for 15 days. Participants were followed up in clinic at 6 weeks and contacted by telephone at 12 weeks. The primary outcome of interest was symptomatic venous thromboembolism; secondary outcomes included bleeding events, transfusion requirements, and death. RESULTS: The incidence of symptomatic deep venous thrombosis at 3 months was 0.5% (n = 18). Only 1 deep venous thrombosis event occurred within 7 days of surgery. The incidence of symptomatic pulmonary embolism (PE) at 3 months was 0.7% (n = 28). Thirteen PEs (46%) occurred within 7 days of surgery. The rate of major bleeding while on prophylaxis was 0.1%. Only 5% of patients received a blood transfusion. No deaths were attributed to thromboembolic events. CONCLUSION: This prospective, observational, phase IV study demonstrates that rivaroxaban appears to protect patients against symptomatic PE and is not associated with major bleeding events when used in a real-world setting as described.

Elimination of Screening Urine Cultures Prior to Elective Joint Arthroplasty.

Discontinuing routine processing of screening urine cultures prior to elective joint arthroplasty resulted in substantial reduction in urine cultures ordered and antimicrobial prescriptions for asymptomatic bacteriuria, without any significant impact on incidence of prosthetic joint infection. This simple change would be scalable across institutions with potential for significant healthcare savings.

Optimizing Pain and Rehabilitation After Knee Arthroplasty: A Two-Center, Randomized Trial.

BACKGROUND: This randomized trial compared (1) continuous femoral nerve block (cFNB), (2) single femoral nerve block (sFNB), and (3) local infiltration analgesia (LIA) with respect to analgesic and functional outcomes after primary tricompartmental knee arthroplasty (TKA). METHODS: One hundred twenty patients undergoing primary tricompartmental knee arthroplasty were randomly assigned to 1 of 3 interventions for postoperative analgesia: (1) cFNB-preoperative bolus of ropivacaine 0.5% 20 mL followed by ropivacaine 0.2% 5 mL per hour for 48 hours; (2) sFNB-preoperative bolus of ropivacaine 0.5% 20 mL with placebo 0.9% saline 5 mL per hour for 48 hours; or (3) LIA-intraoperative tricompartmental injection of ropivacaine 0.2% (150 mL) with epinephrine (10 µg/mL) and ketorolac 30 mg with femoral placebo 0.9% saline 20 mL preoperative bolus and 0.9% saline placebo 5 mL per hour for 48 hours. All participants received an identical, standardized, postoperative multimodal analgesic regimen. Participants, health care providers, data collectors, and analysts were blinded. All participants received identical perineural catheters and perineural/LIA solution (depending on randomized intervention) to maintain blinding. The primary outcome measure was numeric rating scale for pain (NRS) during physiotherapy on postoperative day (POD) 2 at 9:00 AM. Secondary outcomes included opioid consumption, NRS on POD 1 (rest/physiotherapy/worst), functional outcomes, and block complications. RESULTS: For the primary outcome, pain during physiotherapy on POD 2 at 9:00 AM, the overall analysis of covariance (ANCOVA) was significant (P = .049), but pairwise comparisons did not demonstrate any significant differences between treatment arms. NRS was 4.6 (95% confidence interval [CI], 3.3-6.0) for the cFNB group, 4.6 (95% CI, 3.3-6.0) for the sFNB group, and 3.4 (95% CI, 2.2-4.8) for the LIA group. The following is the mean difference in NRS on POD 2 at 9:00 AM among groups: cFNB-LIA (1.2, 95% CI, -0.1 to 2.5; P = .073); sFNB-LIA (1.2, 95% CI, -0.2 to 2.5; P = .097); cFNB-sFNB (0.0, 95% CI, -1.3 to 1.4; P = .996). There were no statistically significant differences between groups in cumulative 48-hour opioid consumption or functional outcomes. cFNB and LIA were superior to sFNB for NRS on POD 1 for worst pain experienced and pain during physiotherapy, respectively. There were no adverse events associated with study procedures reported among participants in the 3 groups. CONCLUSIONS: Our findings suggest no clinically significant differences between cFNB, LIA, and sFNB for pain during physiotherapy on POD 2 after TKA. Secondary analyses suggest that cFNB and LIA are superior to sFNB for early analgesic outcomes (NRS on POD 1) after TKA.

Patients' perceptions of navigating "the system" for arthritis management: are they able to follow our recommendations?

PURPOSE: To understand whether a visit to a Hip/Knee Arthritis Assessment Centre (AC), where non-surgical candidates with arthritis are directed toward community resources and provided with a conservative treatment "prescription," contributes to patients' self-management and ability to access community resources. METHODS: A purposive sample of non-surgical patients was contacted 3-10 months after their AC visit. Three focus groups (n=20) and 20 semi-structured telephone interviews were conducted. Transcripts were systematically coded and analyzed using a qualitative descriptive research methodology. RESULTS: While participants generally reported that the AC visit improved self-management, analysis identified an emergent theme about the inadequacy of conservative management in general, subdivided into two sub-themes related to (1) limited access to high-quality, non-surgical treatment, such as physiotherapy and (2) health care providers' attitudes and approaches, which do not embrace chronic disease prevention and management. CONCLUSIONS: An AC visit contributes to arthritis self-management; however, the current health care system does not adequately support conservative treatment of chronic conditions. Treatment guidelines need to be tailored to the local health care context in which they are applied.

Objectif: Pour comprendre si une visite à un centre d'évaluation de l'arthrite de la hanche ou du genou, où des personnes qui ne sont pas candidates a grave; une intervention chirurgicale et ont de l'arthrite sont dirigées vers des ressources communautaires et reçoivent une « ordonnance ¼ portant sur un traitement de conservation, contribue à l'autoprise en charge par les patients et à leur capacité d'avoir accès aux ressources communautaires. Méthodes: On a communiqué, pendant 3 à 10 mois après leur visite au centre d'évaluation, avec un échantillon choisi à dessein de patients non candidats à une intervention chirurgicale. On a organisé trois groupes de discussion (n=20) et procédé à 20 entrevues téléphoniques semi structurées. Les comptes rendus ont été codés systématiquement et analysés au moyen d'une méthodologie de recherche descriptive qualitative. Résultats: Les participants ont signalé en général que les visites au centre d'évaluation amélioraient l'autoprise en charge, mais l'analyse a dégagé un thème émergent au sujet de l'insuffisance de la prise en charge conservatrice en général, subdivisé en deux sous-thèmes portant sur (1) l'accès limité à un traitement non chirurgical de grande qualité comme la physiothérapie et (2) les attitudes et les approches des fournisseurs de soins de santé qui n'adoptent pas la prévention et la prise en charge des maladies chroniques. Conclusions: Une visite à un centre d'évaluation contribue à l'autoprise en charge de l'arthrite, mais le système de santé actuel n'appuie pas adéquatement un traitement conservateur des problèmes chroniques. Il faut personnaliser les lignes directrices sur le traitement en fonction du contexte local des soins de santé où elles sont appliquées.

Patient-reported compliance with thromboprophylaxis using an oral factor Xa inhibitor (rivaroxaban) following total hip and total knee arthroplasty.

This prospective study examines patient non-compliance (NC) for an oral factor Xa inhibitor (Rivaroxaban) when used as venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. A total of 3145 patients underwent surgery from May 2010 to December 2011. At 6 weeks patients completed an anonymous self-administered questionnaire. Postoperatively 2947 (94%, 2947/3145) received Rivaroxaban. 2824 (96%, 2824/2947) completed all in-hospital doses. Seven percent (203/2824) of patients did not attend the 6-week follow-up. Two thousand one hundred sixty-three (83%, 2163/2621) completed all prescribed doses, 98 (4%, 98/2621) were NC and 360 (14%, 360/2621) had incomplete data. Gender, age, body mass index and preoperative hemoglobin all correlated with NC (p < 0.05). Type and side of surgery did not correlate with compliance (p > 0.05). Patient-reported NC for Rivaroxaban is 4% which compares favorably to other VTE prophylaxis modalities.

Comparing the effects of single shot sciatic nerve block versus posterior capsule local anesthetic infiltration on analgesia and functional outcome after total knee arthroplasty: a prospective, randomized, double-blinded, controlled trial.

Peripheral nerve blocks appear to provide effective analgesia for patients undergoing total knee arthroplasty. Although the literature supports the use of femoral nerve block, addition of sciatic nerve block is controversial. In this study we investigated the value of sciatic nerve block and an alternative technique of posterior capsule local anesthetic infiltration analgesia. 100 patients were prospectively randomized into three groups. Group 1: sciatic nerve block; Group 2: posterior local anesthetic infiltration; Group 3: control. All patients received a femoral nerve block and spinal anesthesia. There were no differences in pain scores between groups. Sciatic nerve block provided a brief clinically insignificant opioid sparing effect. We conclude that sciatic nerve block and posterior local anesthetic infiltration do not provide significant analgesic benefits.

Acetabular cup revision combined with tensor facia lata reconstruction for management of massive abductor avulsion after failed total hip arthroplasty.

We report on 17 patients with massive abductor avulsions after total hip arthroplasty (THA) treated with medialization of the acetabular component and tensor fascia lata (TFL) reconstruction. All patients had severe limp, positive Trendelenburg sign, and avulsion of the abductor insertion confirmed on MRI. Mean age was 69 years (range, 50-83 years), and mean follow-up period was 36 months (range, 18-78 months). After surgery, 9 patients had no limp (47%), 8 patients had a mild limp, and abductor power improved from mean 2.5/5 to mean 3.8 (P < 0.0001). At latest follow-up, the Harris Hip Score was excellent in 6 hips (37%), good in 7 (43%) hips, and fair or poor in 3 (23%). Two patients with mild limp were not satisfied with their procedure.

An intensive perioperative regimen of pregabalin and celecoxib reduces pain and improves physical function scores six weeks after total hip arthroplasty: a prospective randomized controlled trial.

BACKGROUND: Despite the success of total hip arthroplasty (THA), some patients experience persistent pain and poor function after surgery. Predictors of poor outcomes include the presence of significant pre- and postoperative pain. Patients undergoing THA often experience severe, long-standing pain before surgery that may compromise the outcome of the procedure. OBJECTIVES: To evaluate the effects of administering pregabalin and celecoxib for two weeks before and three weeks after THA in patients with moderate to severe pain before surgery. The aim was to determine whether patients with well-controlled pain both before surgery and in the acute postoperative period experience less pain and better physical function six weeks after THA. METHODS: A randomized, double-blinded, placebo-controlled pilot study was conducted. Group 1 received pregabalin (75 mg twice per day) and celecoxib (100 mg twice per day) for 14 days before THA and for three weeks after discharge. Group 2 received a placebo for the same duration. All patients received pregabalin and celecoxib 2 h before surgery and while in the hospital. RESULTS: On the morning of surgery, patients in group 1 reported less pain at rest (mean [± SD] pain intensity measured on a visual analogue scale [VAS] 2.1±1.4) compared with group 2 (3.3±1.9; P=0.04). Patients in group 1 experienced less pain 3 h to 4 h postoperation (P<0.001). There was no difference in morphine consumption between the two groups. Six weeks after THA, movement-evoked pain was lower in group 1 (VAS 0.8±0.6) compared with group 2 (VAS 2.0±1.3; P=0.01). Group 1 reported better physical function, measured using the Western Ontario and McMaster University Osteoarthritis Index questionnaire score (P=0.04). There was no significant difference in 6 min walk test performance between the two groups. CONCLUSION: Intensive pain control with pregabalin and celecoxib improves pain and physical function after THA.

Using outcome measure results to facilitate clinical decisions the first year after total hip arthroplasty.

STUDY DESIGN: Variable-occasion, repeated-measures design. OBJECTIVES: To model change in lower extremity functional status of patients 1 year after total hip arthroplasty (THA), using the Lower Extremity Functional Scale (LEFS) and the 6-minute walk test (6MWT), and, secondarily, to provide clinicians with useful data to guide practice. BACKGROUND: Given the prevalence of THA and current resource pressures, standardized outcome measures play an important role in providing physical therapists with objective knowledge about postoperative recovery and prognosis. METHODS: Seventy-five patients, with a mean age of 61 years and a diagnosis of hip osteoarthritis, consented to participate in the study. Assessments were conducted preoperatively and at multiple time points for up to 65 weeks postoperatively. Recovery was modeled using a nonlinear robust regression analysis for clustered data. The predictive ability of age, body mass index, and preoperative score was explored. RESULTS: Gender-based recovery curves were generated to depict the rate and amount of change in LEFS scores and 6MWT distances over the first year. Preoperative baseline 6MWT distance was the only covariate predictive of postarthroplasty 6MWT distances for both males and females. None of the covariates examined were significantly associated with postarthroplasty LEFS scores. CONCLUSION: Although there were variations in the recovery curves by measure, general patterns were noted. There was a rapid increase in both self-reported and physical performance measure scores for 12 to 15 weeks. Thereafter, we observed a slowing of recovery, with a plateau at 30 to 35 weeks for the 6MWT and later for the LEFS. These data can be used to make evidence-based decisions regarding prognosis and to guide the setting of measurable treatment goals. LEVEL OF EVIDENCE: Prognosis, level 1b.

Gabapentin does not reduce preoperative anxiety when given prior to total hip arthroplasty.

INTRODUCTION: Gabapentin is an anti-epileptic drug which is also used for the treatment of postoperative pain and a variety of psychiatric diseases including chronic anxiety disorders. We tested the hypothesis that compared with a placebo control, gabapentin would reduce preoperative anxiety in patients undergoing total hip arthroplasty. METHODS: Following ethics approval, patients participating in a larger double blind, randomized, trial of multimodal analgesia were given either gabapentin 600 mg (N = 22) or placebo (N = 48) 2 hours before spinal anesthesia. Prior to administering the study medication, baseline anxiety levels were measured using a visual analog scale (VAS). Two hours after the ingestion of gabapentin or placebo, and prior to surgery, patients again rated their anxiety using a VAS. RESULTS: Anxiety scores did not differ significantly between the groups either before (P = 0.95) or 2 hours after (P = 0.61) ingestion of gabapentin or placebo. Baseline anxiety and postdrug anxiety scores failed to demonstrate a significant association with maximal postoperative pain at rest, maximal postoperative pain with movement, and cumulative morphine consumption 48 hours after surgery. CONCLUSIONS: Administration of gabapentin 600 mg prior to surgery does not reduce preoperative anxiety.

Gabapentin decreases morphine consumption and improves functional recovery following total knee arthroplasty.

BACKGROUND: Moderate to severe pain after total knee arthroplasty often interferes with postoperative rehabilitation and delays discharge from hospital. The present study examined the effects of a four-day postoperative gabapentin (GBP) regimen versus placebo on opioid consumption, pain scores and knee flexion, as well as adverse effects, after total knee arthroplasty. METHODS: After obtaining research ethics board approval and informed consent, 40 patients were enrolled in a randomized, single-blind, placebo-controlled, open-label study. Patients were assigned to one of five groups - preoperative placebo/postoperative placebo (G1), preoperative GBP 600 mg/postoperative placebo (G2), preoperative GBP 600 mg/postoperative GBP 100 mg three times per day (G3), preoperative GBP 600 mg/ postoperative GBP 200 mg three times per day (G4) and preoperative GBP 600 mg/postoperative GBP 300 mg three times per day (G5). Postoperative GBP or placebo was continued for four days after surgery. Two hours before surgery, all patients received celecoxib 400 mg. Based on the above groupings, patients in G1 received placebo medication, whereas patients in G2, G3, G4 and G5 received gabapentin 600 mg 2 h preoperatively. All patients received femoral and sciatic nerve blocks, followed by spinal anesthesia. Beginning in the postanesthetic care unit, all patients received a regimen of celecoxib 200 mg every 12 h for four days and a patient-controlled morphine analgesia pump for 48 h. RESULTS: Thirty-six patients (G1, n=7; G2, n=7; G3, n=8; G4, n=7; G5, n=7) completed the study. Data were analyzed by one-way ANOVA followed by a contrast comparing patients who received postoperative GBP (G3, G4 and G5) (n=22) with patients who received placebo postoperatively (G1 and G2) (n=14). Patients who received GBP postoperatively used significantly less patient-controlled morphine analgesia at 24 h, 36 h and 48 h (P<0.05). The postoperative GBP patients had significantly better active assisted knee flexion on postoperative days 2 and 3, with a trend toward better flexion on postoperative day 4. Patients who received GBP postoperatively reported less pruritus than patients who received placebo. There were no differences in pain scores. CONCLUSIONS: These results support the use of GBP in the acute postoperative period. Further trials are needed to delineate the optimal dose, timing and duration of GBP use following surgery.

Toward a joint health and disease management program. Toronto hospitals partner to provide system leadership.

The Joint Health and Disease Management Program in the Toronto Central Local Health Integration Network (TC LHIN) is envisioned as a comprehensive model of care for patients with hip and knee arthritis. It includes access to assessment services, education, self-management programs and other treatment programs, including specialist care as needed. As the first phase of this program, the hospitals in TC LHIN implemented a Hip and Knee Replacement Program to focus on improving access and quality of care, coordinating services and measuring wait times for patients waiting for hip or knee replacement surgery. The program involves healthcare providers, consumers and constituent hospitals within TC LHIN. The approach used for this program involved a definition of governance structure, broad stakeholder engagement to design program elements and plans for implementation and communication to ensure sustainability. The program and approach were designed to provide a model that is transferrable in its elements or its entirety to other patient populations and programs. Success has been achieved in creating a single wait list, developing technology to support referral management and wait time reporting, contributing to significant reductions in waits for timely assessment and treatment, building human resource capacity and improving patient and referring physician satisfaction with coordination of care.