Clinical Usefulness of SPECT/CT for Assessing Postoperative Outcomes After Medial Opening-Wedge High Tibial Osteotomy.

Background: Qualitative studies have explored changes in Tc-99m hydroxymethylene diphosphonate (HDP) uptake on single-photon emission computed tomography and computed tomography (SPECT/CT) as a result of offloading after medial opening-wedge high tibial osteotomy (MOWHTO) in patients with medial compartment knee osteoarthritis. However, whether changes in the Tc-99m HDP uptake on SPECT/CT reflect the degree of clinical improvement in postoperative outcomes, especially when using minimal clinically important differences (MCIDs), has not been investigated. Purpose: To investigate the association between changes in Tc-99m HDP uptake on SPECT/CT and MCID-based improvement on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score in patients who underwent MOWHTO. Study Design: Cross-sectional study; Level of evidence, 3. Methods: The study included 35 knees in 31 patients who underwent MOWHTO. SPECT/CT was performed preoperatively and 3 years postoperatively with clinical and radiological assessments. On SPECT/CT, the knee joint was divided into 10 regions, and the radiotracer uptake amount of each region was divided by the uptake amount of the reference zone. Patients were divided into 2 groups based on whether they achieved the MCID of 16.1 points on the WOMAC at 3 years postoperatively, and changes in uptake amount on SPECT/CT were compared between the groups. Results: At 3 years postoperatively, 22 patients achieved the MCID on the WOMAC (62.9%; above-MCID group) and 13 patients did not (37.1%; below-MCID group). In the above-MCID group, significant improvement was observed in the WOMAC after MOWHTO (from 55.8 to 19.6; P < .05); however, significant improvement was not observed in the below-MCID group (from 38.8 to 32.3; P = .100). Based on mean change of uptake on SPECT/CT in each region, the above-MCID group showed significantly greater reduction of uptake on SPECT/CT than the below-MCID group in the femoral anteromedial compartment (P = .004), tibial anteromedial compartment (P = .009), and tibial anterolateral compartment (P = .031). Conclusion: Reduction in radiotracer uptake on SPECT/CT of the knee joint reflected clinical improvement in patient-reported outcomes following MOWHTO.

Influence of increased pain sensitivity on patient-reported outcomes following total knee arthroplasty.

PURPOSE: The purpose of this study was to discover whether increased pain sensitivity was associated with postoperative pain and patient-reported outcome measures (PROMs) after total knee arthroplasty (TKA). METHODS: Pain sensitivity was evaluated preoperatively using a pain sensitivity questionnaire (PSQ). Resting, walking, nighttime, and average pain visual analog scale (VAS) were measured before surgery and 6 weeks, 3 months, 6 months, and 1 year after surgery. PROMs were also evaluated based on the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and patient satisfaction. The association between pain VAS average score, WOMAC total score, and PSQ score (minor, moderate, and total score) was assessed at each stage. RESULTS: There were 59 patients with a high PSQ score (≥ 5.2) and 53 with a low PSQ score (< 5.2). Up to 1 year postoperatively, the group with high PSQ scores had higher resting, walking, nighttime, and average pain VAS scores than the group with low scores (all p < 0.05). Worse preoperative WOMAC pain, function, and total scores continued until 1 year after surgery in the high-scoring PSQ group (all p < 0.05). The group with low PSQ scores was more satisfied with surgery than the group with high scores (p = 0.027). There was a positive correlation between preoperative PSQ score and pain VAS average score at all time points (all p < 0.05). A relationship between PSQ score and WOMAC total score was also observed (all p < 0.05). CONCLUSION: Increased pain sensitivity is a factor related to higher postoperative pain levels and inferior PROMs in patients undergoing primary TKA. LEVEL OF EVIDENCE: Case-controlled study, III.

Intravenous Tranexamic Acid Has Benefit for Reducing Blood Loss after Open-Wedge High Tibial Osteotomy: A Randomized Controlled Trial.

(1) Background: the purpose of this study was to investigate the efficacy and safety of intravenous (IV) administration of tranexamic acid (TXA) in patients undergoing medial opening wedge high tibial osteotomy (MOWHTO). (2) Methods: a total of 73 patients were randomly allocated into two groups (TXA group and control group). The primary outcome was total perioperative calculated blood loss after MOWHTO. Secondary outcomes included self-reported pain severity using a 10-point visual analog scale (VAS) and the EuroQol-5 Dimension (EQ-5D) questionnaire. The postoperative allogeneic transfusion rate and wound complications were compared. Deep vein thrombosis (DVT) incidence was compared by conducting DVT computed tomography imaging. (3) Results: the total blood loss after surgery was 470.9 mL in the TXA group and 739.3 mL in the control group, showing a significant difference (p < 0.001). There were no differences in pain VAS scores between the two groups (all p > 0.05). No difference in preoperative EQ-5D scores for any items existed between the two groups. No transfusion was performed in either group. There was no difference in DVT incidence or the rate of wound complications between the two groups. (4) Conclusion: in patients undergoing MOWHTO, IV TXA reduces total blood loss and drainage amount. However, no additional benefits in clinical outcomes, transfusion rate, or wound complications were apparent, with similar DVT incidence rates.

Preemptive Duloxetine Relieves Postoperative Pain and Lowers Wound Temperature in Centrally Sensitized Patients Undergoing Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

(1) Background: The purpose of this study was to determine whether preemptive duloxetine in patients with central sensitization (CS) is effective for acute postoperative pain control and wound healing following total knee arthroplasty (TKA). (2) Methods: CS was defined as a score of 40 points or higher on the Central Sensitization Inventory (CSI) survey. Thirty-nine patients with CS were randomly assigned to either the duloxetine group (n = 19) or the placebo group (n = 20). The duloxetine group took duloxetine 30 mg once a day, while the placebo group took the placebo medication once a day. A pain visual analog scale (VAS) and the Brief Pain Inventory (BPI), wound complications, the temperature of the surgical site, and adverse events were investigated. Skin temperature was measured at the center of the patella using a portable digital thermometer. (3) Results: The duloxetine group reported significantly lower pain VAS scores during follow-up periods up to 6 weeks after surgery (all p < 0.05). BPI interference also showed significantly superior results in the duloxetine group after surgery (all p < 0.05). Although there was no difference in the rate of wound complications between the two groups (p > 0.05), the duloxetine group showed significantly lower wound temperature than the placebo group during the follow-up period (all p < 0.05). (4) Conclusion: In this study, preemptive duloxetine effectively reduced pain and lowered wound temperature following TKA in CS patients.

Efficacy and safety of celecoxib combined with JOINS in the treatment of degenerative knee osteoarthritis: study protocol of a randomized controlled trial.

BACKGROUND: The aim of this study will be to investigate the therapeutic effect and safety of non-steroidal anti-inflammatory drugs (NSAIDs) along with symptomatic slow-acting drugs for the treatment of osteoarthritis (SYSADOA), JOINS tablets, for degenerative knee osteoarthritis (OA) treatment and to determine the analgesic and anti-inflammatory effects of the combination therapy. In addition, we will investigate whether JOINS treatment alone after NSAID and JOINS combination treatment is effective in relieving and maintaining knee OA symptoms. METHODS: This study will be a prospective, randomized, double-blind endpoint study design. All patients will be randomly assigned to either intervention (celecoxib+JOINS) or control (celecoxib+placebo) groups. In Part 1, the intervention group will be administered celecoxib once a day and JOINS three times a day for a total of 12 weeks. In the control group, celecoxib will be administered once a day and JOINS placebo three times a day for a total of 12 weeks. In Part 2, JOINS alone and JOINS placebo alone will be administered for an additional 24 weeks in both groups, respectively. The primary endpoint will be the amount of change during the 12 weeks as assessed using the Western Ontario and McMaster Universities Osteoarthritis Index total score compared with baseline. The secondary endpoint will be the amount of change at 1, 4, 12, 24, and 36 weeks from the baseline for pain visual analog scale, Brief Pain Inventory, Short Form Health Survey-36 and biomarkers. RESULTS: The trial was registered with Clinical-Trials.gov (NCT04718649). The clinical trial was also registered on Clinical Research Information Service (CRIS) with the trial registration number KCT0005742. CONCLUSIONS: The combination treatment of the most commonly used SYSADOA drug, JOINS, and selective COX-2 inhibitor celecoxib as the representative NSAID for knee OA treatment, can be compared with celecoxib alone treatment to determine the safety or therapeutic effect.

The Minimal Clinically Important Difference (MCID) for the WOMAC and Factors Related to Achievement of the MCID After Medial Opening Wedge High Tibial Osteotomy for Knee Osteoarthritis.

BACKGROUND: Many approaches have been used to determine the minimal clinically important difference (MCID) in patients undergoing total knee arthroplasty, but the MCID for outcome measures after medial opening wedge high tibial osteotomy (MOWHTO) for the treatment of medial compartment knee osteoarthritis (OA) has not been reported. PURPOSE: To define the MCID for the Western Ontario and McMaster Universities Arthritis Index (WOMAC) after MOWHTO and to identify risk factors for not achieving the MCID. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Among patients with medial compartment knee OA who underwent MOWHTO, 174 patients who were followed for 2 years were included in the study. The MCID and substantial clinical benefit (SCB) for the WOMAC were determined using the anchor-based method with a 15-item questionnaire. Preoperative OA severity was measured by the Kellgren-Lawrence (K-L) grading system, and the acceptable range of the postoperative weightbearing line ratio was 50% to 70%. Patients were divided into 2 groups based on whether the MCID and SCB were achieved, and then factors related to failure to achieve the MCID and SCB were analyzed using multivariate logistic regression analysis. RESULTS: The MCID for the WOMAC was 4.2 points for the pain subscale, 1.9 points for the stiffness subscale, 10.1 points for the function subscale, and 16.1 points for the total. Additionally, the SCB for the WOMAC was 6.4 for pain, 2.6 for stiffness, 16.4 for function, and 25.3 for the total. Overall, 116 (66.7%), 99 (56.9%), 127 (73.0%), and 128 (73.6%) patients achieved the MCID for the WOMAC pain, stiffness, function, and total, respectively, after MOWHTO. The odds of not achieving the MCID for the WOMAC total were 1.09 times greater (95% CI, 1.05-1.13; P < .001) in patients with a low preoperative WOMAC total score (cutoff values: 10.5 for pain, 3.5 for stiffness, 34.5 for function, and 51.0 for the total), 11.77 times greater (95% CI, 3.68-37.70; P < .001) in patients with K-L grade 4 OA compared with K-L grades 2 or 3 OA, and 8.39 times greater (95% CI, 2.98-23.63; P < .001) in patients with undercorrection or overcorrection. A low preoperative WOMAC score, K-L grade 4 OA, and undercorrection or overcorrection were also associated with not achieving the SCB for the WOMAC total (all P < .05). CONCLUSION: Patients treated with a MOWHTO require a 16.1-point improvement in the WOMAC total score to achieve a MCID from the procedure. Low preoperative WOMAC scores, severe OA, and undercorrection or overcorrection were related to failure to achieve the MCID.

Alignment adjustment using the Valgus stress technique can increase the surgical accuracy of novice surgeons during medial opening-wedge high Tibial osteotomy.

BACKGROUND: The purpose of this study was to compare the degree of accuracy of coronal alignment correction with use of the "alignment adjustment under valgus stress technique" between expert and novice surgeons during medial opening-wedge high tibial osteotomy (MOWHTO). METHODS: Forty-eight patients who underwent MOWHTO performed by an expert surgeon (expert group) and 29 by a novice surgeon (novice group) were enrolled in analysis. During surgery, lower-extremity alignment was corrected using the "alignment adjustment under valgus stress technique". Normocorrection was defined as a weight-bearing line ratio between 55 and 70% and the correction accuracy was compared between expert and novice groups using the ratio of normocorrection to outliers. The clinical outcomes were also compared using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at 1 year after surgery. RESULTS: The undercorrection rate was 14.6% in the expert group and 13.8% in the novice group, while the overcorrection rate was 2.1% in the expert group and 3.4% in the novice group. In the ratio of normocorrection to outliers, no difference was found between the two groups at the one-year follow-up visit (83.3% in the expert group vs. 82.8% in the novice group; p > 0.05). Also, no significant differences were seen in WOMAC subscores immediately preoperatively and at 1 year after surgery (all p > 0.05). CONCLUSION: Adhering to the "alignment adjustment under valgus stress technique" protocol enabled novice surgeons to achieve similar surgical accuracy as that of an expert surgeon in coronal alignment during MOWHTO. LEVEL OF EVIDENCE: Level III.

2-Octyl Cyanoacrylate Topical Adhesive as an Alternative to Subcuticular Suture for Skin Closure After Total Knee Arthroplasty: A Randomized Controlled Trial in the Same Patient.

BACKGROUND: The 2-octyl cyanoacrylate topical adhesive with flexible self-adhesive polyester mesh (Dermabond Prineo) is becoming widely used in many surgical fields. However, no prior studies have tested the efficacy and safety of this topical adhesive compared with subcuticular suture in the same patient. The purpose of this study was to compare the efficacy and safety between Dermabond Prineo and subcuticular suture for skin closure in patients undergoing same-day bilateral total knee arthroplasties (TKAs). MATERIALS AND METHODS: A prospective, double-blind randomized controlled trial was performed in 51 patients scheduled to undergo same-day bilateral TKAs. One knee was randomly assigned to the Dermabond Prineo and the other knee was allocated to the subcuticular suture. As primary outcomes, Vancouver scar scale was evaluated at 6 months and Patient and Observer Scar Assessment Scale was evaluated at 2 weeks, 6 weeks, 3 months, and 6 months. Secondary outcomes included cosmesis efficacy (Hollander wound evaluation scale [HWES] and cosmesis visual analog scale [VAS]), time and pain efficiency (skin suture time, stitch out time, and stitch out pain VAS), and safety (wound complications during the 6-month follow-up period). The primary and secondary outcome measures were compared between groups. RESULTS: There were no significant differences in Vancouver scar scale and Patient and Observer Scar Assessment Scale at 6 months. Although there were no significant differences in HWES at 2 weeks, the Dermabond Prineo group showed better step-off border item of HWES. There was also no difference in cosmesis VAS at 6 months. The Dermabond Prineo group showed superior results in terms of time (suture time: Dermabond Prineo = 191 second (sec) ± 60.1 sec, subcuticular suture = 356.8 sec ± 92.3 sec; stitch out time: Dermabond Prineo = 4 sec ± 1.3 sec, subcuticular suture = 26.6 sec ± 4.2 sec, all P < .001) without significant differences in pain scale (P = .823) or wound complications (all P > .05). CONCLUSION: Comparing cosmetic efficacy, time efficiency, and safety, Dermabond Prineo provided quicker wound closure, shorter stitch out time, and better wound margin coaptation in the early postoperative period but similar cosmetic efficacy compared with subcuticular suture. Based on our study, Dermabond Prineo is a useful alternative to subcuticular suture in patients undergoing TKA. LEVEL OF EVIDENCE: Therapeutic level 1.