Comparison of the Effect of Intra-Articular, Periarticular, and Combined Injection of Analgesic on Pain Following Total Knee Arthroplasty: A Double-Blinded Randomized Clinical Trial.

The aim of this study was to compare the efficacy of 3 methods of intraoperative analgesic cocktail injection during total knee arthroplasty (TKA)-intra-articular (IA), periarticular (PA), and combined intra-articular and periarticular (IA+PA)-on controlling early postoperative pain. Methods: This was a prospective double-blinded parallel randomized clinical trial. A total of 153 patients scheduled for TKA were allocated to IA, PA, or IA+PA (51 patients each) by block randomization. The primary outcome was morphine consumption. Secondary outcomes were visual analogue scale (VAS) pain, knee flexion, straight leg raising, Knee Society Score (KSS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Results: The morphine consumption was lowest in the PA group (median = 0, interquartile range [IQR] = 5) and highest in the IA group (median = 10, IQR = 5). The PA group had significantly lower VAS pain at rest than either IA (mean difference = -0.70; 95% confidence interval [CI] = -0.93 to -0.46; p < 0.001) or PA+IA (mean difference = -0.41; 95% CI = -0.65 to -0.18; p < 0.001). The PA group had also lower VAS pain during activity compared with IA (mean difference = -0.63; 95% CI = -0.85 to -0.40; p < 0.001) and IA+PA (mean difference = -0.38; 95% CI = -0.61 to -0.16; p < 0.001). The PA group had significantly greater active knee flexion compared with IA (mean difference = 9.68°; 95% CI = 5.50° to 13.86°; p < 0.001) and IA+PA (mean difference = 5.13°; 95% CI = 0.95° to 9.31°; p = 0.010). Passive knee flexion was greater for PA than IA (mean difference = 7.85°; 95% CI = 4.25° to 11.44°; p < 0.001). Other outcome variables were not significantly different among the 3 groups. The only complications were wound drainage (1 each in the IA and IA+PA groups) and deep venous thrombosis (1 in the IA group). Conclusions: PA was associated with less early postoperative pain and greater active knee flexion compared with the other 2 analgesic methods. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intra-Articular Ganglion Cysts of the Knee.

➢: Magnetic resonance imaging (MRI) without contrast is sufficient to diagnose an intra-articular ganglion cyst of the knee. MRI with intravenous contrast may be considered for cysts in the infrapatellar fat pad, which are not a typical presentation. ➢: The current literature supports treating symptomatic cases or those discovered accidently during knee arthroscopy with arthroscopic excision. ➢: Although aspiration of these cysts results in a higher recurrence rate than excision, it is associated with quicker recovery. Thus, aspiration might be chosen as an initial treatment for anyone who would like to avoid surgery or requires a rapid recovery, including professional athletes. ➢: Open excision may be considered for infrapatellar fat pad cysts that are >4.5 cm in size.

Restoring femoral medial offset could reduce pelvic obliquity following primary total hip arthroplasty, an observational study.

BACKGROUND: Since femoral and horizontal offsets may be contributing factors to hip and pelvic balance, this study seeks to determine whether there is a correlation between pelvic obliquity (PO) after unilateral total hip arthroplasty (THA) and horizontal/vertical offset differences of the replaced and contralateral natural joints. METHODS: A cross-sectional study was performed on adult patients who underwent unilateral THA between 2017 and 2020. An expert orthopaedic resident measured PO angles and offset parameters. "Delta medial offset" is considered medial offset of the replaced hip minus the medial offset of the contralateral side. "Absolute delta medial offset" is considered the absolute value of the "Delta medial offset." RESULTS: Finally, 133 patients were included in the study with a mean (SD) age of 45.3 ± 14.8 years and 57.9% female. The PO values (median, IQR) changed from 3.2 (1.7-5.7) before THA to 3.0 (1.50-5.6) after THA, not significantly decreased (P = 0.31). The PO after THA is significantly correlated with PO before THA (correlation coefficient of 0.457, P < 0.001), the delta medial offset after THA (correlation coefficient of - 0.24, P = 0.006), and the absolute delta medial offset after THA (correlation coefficient of 0.284, P = 0.001). The amount of changes of delta medial offset, before and after surgery, was not significantly correlated to PO or PO changes after surgery. CONCLUSION: PO before the THA and medial offset discrepancy after THA are two important contributing factors for post-operative PO. Restoring the medial offset of the affected side and lowering the delta medial offset between the two sides can significantly decrease post-operative PO.

Effect of joint immobilization using extension splint immediately after total knee arthroplasty on post-operative knee function and pain: a randomized clinical trial.

PURPOSE: Investigate the effect of semirigid extension bracing after total knee arthroplasty (TKA) on articular pain and function. METHODS: The present randomized clinical trial included 72 patients undergoing unilateral primary TKA. Patients in the case group received eight days of post-operative semirigid extension-locked knee bracing, whereas controls did not. The outcomes assessed preoperatively and on the first, ninth, 30th day, and one year post-operatively included the knee society score (KSS), functional KSS (FKSS), VAS pain score, amount of postoperative opiate painkiller usage (tablet oxycodone 5mg), and knee ROM. RESULTS: The case group had a significantly lower flexion ROM on postoperative day nine compared to the control group (95.3° vs. 100.8°, p=0.03), while it became significantly higher 1 month (114.1° vs. 104.7°, p=0.03) and one year post-operative (128.0° vs. 120.5°, p=0.002). Also, FKSS was significantly higher in the case group than in the controls in the one month post-operative assessment (37.0 vs. 32.6, p=0.009) but not in the one year post-operative assessment. The case group patients had a significantly lower pain than the controls on days one (5.8 vs. 7.2, p=0.02) and nine post-operative (4.1 vs. 5.2, p=0.048), but not at later assessments. The amount of one month post-operative opium (oxycodone) consumption was significantly lower in the brace group (12.4 vs. 14.1 tablets, p=0.03). The KSS were not significantly different between the groups after the surgery. CONCLUSION: Extension-locked splinting immediately after TKA is a noninvasive, non-pharmacological, and inexpensive intervention with possible promising effects on knee ROM, short-term functional improvement, and acute post-operative pain management.

Cementless total hip arthroplasty in haemophilia patients through direct anterior approach.

INTRODUCTION: Total hip arthroplasty (THA) has become the treatment of choice for patients with severe haemophilic arthropathy of the hip. However, the intraoperative and postoperative complications, including blood loss and infection, are significant concerns. Direct Anterior Approach (DAA) might be beneficial in THA of patients with haemophilia. AIM: The present study was conducted to assess outcomes of THA using DAA in patients with haemophilia. METHODS: We retrospectively reviewed our joint replacement database. From January 2010 to December 2015, we had 12 patients with haemophilia who underwent 14 THAs by DAA and followed for an average of 69 months. RESULTS: All patients were male with a mean age of 36 ± 7 years at the time of THA. The mean Harris Hip Score improved from 46 preoperatively to 89 at the final follow-up visit. One dislocation and one infection occurred. Only one patient with simultaneous bilateral THA needed a transfusion. All components were radiologically well fixed at the final follow-up visit except one acetabular loosening that needed revision. All patients were satisfied with the outcome of the surgery at the final follow-up visit. CONCLUSION: In this study, it was observed that complications of cementless THA using DAA in haemophilia patients with hip arthropathy are comparable to other surgical approaches. However, the complication of bleeding in this approach might be less.

No difference in union and recurrence rate between iliac crest autograft versus allograft following medial opening wedge high tibial osteotomy: a randomized controlled trial.

PURPOSE: Using iliac crest autograft has been considered as gold standard for gap filling in medial opening wedge high tibial osteotomy (MOW-HTO) but is associated with donor site morbidity and pain. The purpose of this study was to compare the results of the use of iliac crest autograft versus allograft from the same anatomic site in terms of union and recurrence. METHODS: Forty-six patients with genovarum with or without medial compartment osteoarthritis were enrolled based on specific inclusion and exclusion criteria and were randomly assigned into two groups. MOW-HTO was done using iliac crest allograft (23 patients) or autograft (23 patients) as void filler. Follow-up visits were done monthly for the first 3 months and then every 3 months until 1 year and then at 5th and 8th postoperative year. The clinical assessment of union, anatomical indices of proximal tibia, complications and WOMAC score were assessed for both groups. RESULTS: The amount of correction (degrees), recurrence, complication rates, time to get symptom-free, radiologic union and knee scores was similar in both groups. The symptom-free time was 6.1 (SD = 0.9) weeks in autograft group versus 6.2 (SD = 0.8) weeks in allograft group (p = 0.73, 95% CI - 0.4 to 0.6). The time to radiologic union had a between-group difference of 0.3 weeks (p = 0.58, 95% CI - 1.6 to 0.9). There was one case of surgical site infection in graft harvest site. No nonunion or delayed union was encountered in either group. Fifty-two percent of the autograft patients reported more intense postoperative pain in iliac graft harvest site than tibial osteotomy site. CONCLUSIONS: According to our results, iliac crest allograft can be safely used in MOW-HTO with comparable efficacy and safety to iliac crest autograft. CLINICAL TRIAL REGISTRY: The clinical trial was approved by clinicaltrial.gov with identifier NCT00595712.

The long-term effects of radioactive phosphorous synoviorthesis on hemophilic arthropathy.

BACKGROUND: Radioactive synoviorthesis was carried out by an injection of radioactive materials into the joint that has been known as a successful alternative treatment to invasive surgical synovectomy. This study was designed to evaluate short-term and long-term results and complications of radioactive synovectomy of hemophilic arthropathy using radioactive phosphorus. MATERIALS AND METHODS: This study was conducted on 40 patients with hemophilic arthropathy. After obtaining clotting factors, the intra-articular injections of radioactive phosphorus were done. Thirteen patients were evaluated during 36 months (short-term follow-up) and 27 patients were followed up for more than 36 months (long-term follow-up). Patients were evaluated for hemarthrosis, factor consumption per month, joint range of motion (ROM) and clinical and radiological involvement grade. RESULTS: The patients mean age was 22.9 ± 6.6 and there were 38 men and 2 women. Consumption of clotting factors was significantly reduced in the short-term follow-up of patients (p < 0.05), but there was no significant difference in the long-term follow-up (p > 0.05). ROM decreased significantly in the long-term follow-up (p < 0.05). Radiologic evaluation showed significantly increased involvement in their joints (p < 0.05). CONCLUSION: Using radioactive synoviorthesis led in decreased consumption of clotting factors and the hemarthrosis incidence in short term but it did not have significant impact on clinical situation (ROM) and radiological findings of hemophilic patients in long-term follow-up.