Artroplastía total de rodilla con asistencia de brazo-robótico: resultados clínicos postoperatorios tempranos / Robotic arm-assisted total knee arthroplasty: early postoperative results

OBJETIVO: Describir los resultados clínicos postoperatorios tempranos de la primera serie de pacientes operados de artroplastía total de rodilla (ATR) con asistencia de brazo-robótico en Latinoamérica. MATERIALES Y MÉTODOS: Estudio prospectivo de 52 pacientes (53 rodillas) con gonartoris tricompartimental sintomática operados de ATR primaria con asistencia de brazo-robótico (RIO-MAKO) de manera consecutiva, con seguimiento a 2 meses postoperados. No se excluyeron pacientes. Se utilizó el mismo protocolo anestésico y de rehabilitación. Se realizó revisión de fichas clínicas para recolectar los siguientes resultados: tiempo de isquemia quirúrgica, estadía hospitalaria, tiempo a marcha, dolor postoperatorio diario [Escala visual análoga (EVA)], uso de opioides, rangos de movilidad articular (ROM), pérdida sanguínea, complicaciones y eje mecánico postoperatorio. RESULTADOS: Tiempos de Isquemia: 82 minutos (60­120). Estadía Hospitalaria: 4 días (2­12). Dolor postoperatorio: EVA el mismo día operatorio de 0 (0­10) y previa al alta de 0 (rango 0­4), con 0,3 purgas (0­6,5) de opioides por paciente. Tiempo a marcha (día logrado): 1 día (1­3), cuarenta y cinco pacientes (84,9%) iniciaron la marcha el primer día postoperatorio. ROM (Extensión-Flexión): Aumento progresivo durante el seguimiento. En el control ambulatorio de los dos primeros meses [23 días (13­50)], veintiún pacientes (40%) alcanzaron un ROM mayor o igual a 0­90° y once (20%) presentaron un ROM funcional máximo (0­120°). Pérdida sanguínea: Siete pacientes (13,2%) requirieron transfusión. Complicaciones: un paciente (1,89%) presentó una dehiscencia del cierre de la artrotomía. No hubo otras complicaciones. Eje mecánico postoperatorio: 179,1° (178,2­180). DISCUSIÓN: Los resultados concuerdan con la evidencia descrita en otras regiones, sugiriendo que la asistencia de brazo-robótico permite resultados postquirúrgicos reproducibles. CONCLUSIÓN: Los resultados clínicos postoperatorios tempranos de esta serie de pacientes operados de ATR con asistencia de brazo-robótico, muestran una baja percepción del dolor, con bajo consumo de opioides, una rápida recuperación funcional de la marcha y ROM, y excelentes resultados desde el punto de vista del eje mecánico postoperatorio. NIVEL DE EVIDENCIA: IV.

OBJECTIVE: Describe the early clinical postoperative outcomes, of the first series of patients operated on Robotic Arm-Assisted Total Knee Arthroplasty (TKA) in Latin America. MATERIAL AND METHOD: Retrospective study including 52 patients (53 knees) with advanced symptomatic knee osteoarthritis, consecutively operated on Robotic ArmAssisted TKA (RIO-MAKO) during October 2018 and May 2019 with two months of follow-up. No patients were excluded from the study. The same anesthetic and rehabilitation protocol was followed for all patients. Data were obtained from the clinical files for the following outcomes: Surgical tourniquet time, hospital stay, time to walk, postoperative daily pain [Visual Analog Scale (VAS)], opioid consumption, range of motion (ROM), blood loss, complications, and the attained postoperative mechanical axis. RESULTS: Tourniquet Time: 82 minutes (60­120). Hospital Stay: 4 days (2­12). Postoperative Pain: VAS of 0 (0­10) the same day of surgery, and 0 (0­4) before discharge. The opioid consumption was 0,3 purge (0­6,5) per patient. Time to Walk (Day achieved): 1st day (1­3), forty-five patients (84,9%) walked on their first postoperative day. ROM (Extension-Flexion): progressively increases during the follow up. On the first two-month visits [23 days (13­50)], twenty-one patients (40%) reached a ROM equal or superior to 0­90°, and eleven (20%) presented a maximal functional ROM (0­120°). Blood Loss: Seven patients (13.2%) required a blood transfusion. Complications: one patient (1.89%) presented dehiscence of the arthrotomy closure. No other complications were registered. Postoperative Mechanical Axis: 179.1° (178.2­180). DISCUSSION: The results coincide with the reported evidence from other regions. Robotic-arm assistance may generate reproducible postoperative results. CONCLUSIONS: The early postoperative clinical results of this series of patients operated on Robotic Arm-Assisted TKA show a low pain perception and opioid use, a rapid functional rehabilitation in terms of gait and ROM, and excellent postoperative mechanical alignment. LEVEL OF EVIDENCE: IV.

Ultrasound-guided adductor canal block using levobupivacaine versus periarticular levobupivacaine infiltration after totalknee arthroplasty: a randomized clinical trial

ABSTRACT BACKGROUND: Both postoperative pain control and range of motion are important in total knee arthroplasty (TKA). However, in the literature, there is little comparison of peripheral nerve blocks and periarticular infiltration techniques using levobupivacaine. The aim of our study was to measure pain with visual analogue scale (VAS) and knee range of motion (ROM) between in patients undergoing adductor canal block (ACB) for TKA using levobupivacaine compared to periarticular levobupivacaine infiltration (PAI-L). DESIGN AND SETTING: Prospective randomized clinical trial in a university hospital. METHODS: Patients aged 40-85 years who underwent unilateral TKA were included; 39 were treated withperiarticular infiltration using 40 ml (0.125 mg) of levobupivacaine (PAI-L group); and 40 were treated with ACB using 20 ml of 0.25% levobupivacaine (ACB-L group). Postoperative pain scores at rest and during active physical therapy were assessed using a VAS, along with knee ROM in flexion and extension. In addition, 100-foot walking time results, total morphine consumption and time of first analgesia requirement were recorded postoperatively. RESULTS: VAS scores at rest and during active physical therapy and the total amount of morphine consumed were lower in the ACB-L group than in the PAI-L group (P < 0.05). In contrast, knee ROM in flexion and extension and 100-foot walking times were greater in the PAI-L group than in the ACB-L group (P < 0.05). CONCLUSION: ACB-L was superior to PAI-L regarding pain treatment after TKA; however, PAI-L was superior to ACB-L regarding postoperative ROM and walking ability. CLINICAL TRIAL REGISTRY: ACTRN-12618000438257.

Uso tópico de ácido tranexámico en el reemplazo total de rodilla primario / Topical administration of tranexamic acid in primary total knee replacement

Introducción: El reemplazo total de rodilla es un procedimiento que puede generar una gran perdida de sangre durante el periodo posoperatorio. El acido tranexamico es un agente sintetico antifbrinolitico que, en los ultimos anos, se ha administrado por via intravenosa, con buenos resultados, al reducir el sangrado asociado al reemplazo total de rodilla. Sin embargo, existe escasa experiencia con su uso topico. Materiales y Métodos: Se llevo a cabo un estudio comparativo retrospectivo de 117 reemplazos totales de rodilla primarios, para comparar los resultados obtenidos en 63 cirugias con el uso topico de acido tranexamico y en 54 reemplazos sin acido tranexamico. Se compararon la tasa de transfusion, las concentraciones de hemoglobina y hematocrito a las 24 y 48 h, las curaciones requeridas, las comorbilidades y las complicaciones. Resultados: En el grupo con acido tranexamico topico, se redujo un 43,9% la tasa de transfusiones cuando se lo comparo con el otro grupo. Ademas, se registro una disminucion de 0,2-1,3 g/dl en la caida de la hemoglobina a las 24 h de la cirugia. No se detectaron complicaciones. Conclusiones: El uso topico de acido tranexamico en reemplazos totales primarios de rodilla disminuye los requerimientos de transfusiones, sin incrementar el riesgo de complicaciones. Nivel de Evidencia: III

Introduction: Total knee replacement is associated with extensive postoperative blood loss. Tranexamic acid is a synthetic antifibrinolytic agent that, in the last few years, has been successfully used intravenously to reduce bleeding after total knee replacement. However, topical application of tranexamic acid in total knee replacement remains largely unexplored. Methods: A retrospective study of 117 primary total knee replacements was conducted: 63 surgeries with topical tranexamic acid and 54 replacements without tranexamic acid. A comparison analysis was made, capturing results of blood transfusion rates, postoperative hemoglobin levels (24 and 48 hours), number of changed bandages, comorbidities and complications. Results: Tranexamic acid reduced blood transfusion rate by 43.9% when compared with the group without tranexamic acid. A lower decline in postoperative hemoglobin levels (24 hours) by 0.2-1.3 g/dL was also observed in this same group. There were no complications in both groups. Conclusions: Topically applied tranexamic acid was effective in reducing the need for blood transfusion following total knee replacement, without additional adverse effects. Level of Evidence: III

Reemplazo parcial de rodilla mediante el sistema robótico NAVIO: resultados clínicos postquirúrgicos evaluados mediante Knee injury Osteoartritis Outcome Score / Robotic-assisted unicompartmental knee replacement with NAVIO surgical system: outcome evaluation using the Knee Injury Osteoarthritis Outcome Score

INTRODUCCIÓN: La osteoartritis de rodilla es una de las patologías musculo esqueléticas más prevalentes en el mundo, y el tratamiento quirúrgico es hasta hoy, la única terapia definitiva. El sistema NAVIO™ es uno de los dispositivos robóticos más recientemente a disposición para realizar el reemplazo parcial de rodilla. Ofrece gran precisión en el proceso de alineamiento, remodelado óseo y balance de los tejidos blandos, sin exponer al paciente a la radiación ni a los costos de la tomografía computarizada que suele realizarse con los sistemas robóticos actuales antes del procedimiento artroplástico. OBJETIVO: Evaluar los resultados medidos por los pacientes antes y después del procedimiento artroplástico mediante NAVIO™ y la prótesis STRIDE™. MATERIAL Y MÉTODO: Aplicación del cuestionario Knee injury Osteoarthritis Outcome Score (KOOS) en el preoperatorio y a los 12 meses del procedimiento quirúrgico de los primeros 47 pacientes operados usando NAVIO™ en Cornerstone Regional Hospital, Edinburg, Texas. RESULTADOS: Se observó una mejoría de las muestras normalizadas en todas las categorías con un p < 0.05. COMENTARIO: Estudios recientes han sugerido que en Chile la presentación de la osteoartritis se asocia a un grado de severidad menor que en el resto de los países latinoamericanos. Lo cual torna relevante la aplicación de terapias quirúrgicas más conservadoras, que ofrezcan al paciente un alivio sintomático y le permitan reestablecerse a sus actividades cotidianas causando el mínimo impacto posible. Esas ventajas fueron observadas en los pacientes sometidos a ese procedimiento quirúrgico. CONCLUSIONES: La artroplastia unicompartimental de rodilla mediante el sistema quirúrgico NAVIO™ y prótesis STRIDE™ demostró mejorar substancialmente la vida diaria y calidad de vida de los pacientes, disminuyendo el dolor y mejorando su función durante las actividades deportivas y recreacionales.

INTRODUCTION: Knee osteoarthritis is one of the most prevalent musculoskeletal pathologies in the world and the surgical treatment is until today the only definitive therapy. NAVIO™ system is one of the most recently available robotic devices for partial knee arthroplasty. It offers great precision in the process of alignment, bone remodeling and soft tissue balancing without exposing the patient to the radiation or the costs of the CT scan usually performed before the arthroplasty with the current robotic systems. OBJECTIVE: To evaluate the outcomes measured by the patients before and after the arthroplasty using NAVIO™ and the STRIDE™ prosthesis. MATERIALS AND METHODS: Application of the Knee Injury Osteoarthritis Outcome Score (KOOS) questionnaire in the preoperative and 12 months after the surgical procedure of the first 47 patients operated using NAVIO™ at Cornerstone Regional Hospital, Edinburg, Texas. RESULTS: There was an improvement of the normalized samples in all the categories with p < 0.05. COMMENTARY: Recent studies have suggested that in Chile the presentation of osteoarthritis is associated with a lower degree of severity compared with the rest of Latin American countries. This makes relevant the application of more conservative surgical therapies, which could offer the patient symptomatic relief and allow them to reestablish their daily activities causing the minimum impact possible. These advantages were observed in patients undergoing this surgical procedure. CONCLUSIONS: Unicompartmental knee replacement using NAVIO ™ surgical system and STRIDE™ prosthesis demonstrated a substantial improvement in patient's quality of life, reducing pain and improving their function during sports and recreational activities.

Plasma rico em plaquetas (PRP) aplicado na artroplastia total do joelho / Platelet-rich plasma (PRP) applied in total knee arthroplasty

Avaliar, através de um estudo clinico, randomizado, controlado e cego, a eficácia do plasma rico em plaquetas na cicatrização, dor e hemostasia após artroplastia total do joelho. Metodologia: Foram selecionados 40 pacientes que seriam submetidos a prótese total do joelho e randomizados. Em 20 destes pacientes foi aplicado o plasma rico em plaquetas antes do fechamento da cápsula articular. Foram realizadas dosagens de hemoglobina (mg/dL) e hematócrito (%) no pré-operatório, após 24 e 48 horas da cirurgia. Aplicado o questionário WOMAC, a escala verbal da dor e medidas as amplitudes de movimento do joelho até o 2o mês pós-operatório. A análise estatística comparou os resultados afim de comprovar haver diferença entre os grupos em cada um dos momentos da avaliação. Resultados: Medidas do valor da hemoglobina (mg/dL) e hematócrito (%) realizadas no pré-operatório, após 24 e 48 horas da cirurgia não mostraram diferenças significativas entre os grupos (p>0,05). O questionário WOMAC e a amplitude de movimento medidas no pré-operatorio e até os dois primeiros meses também não mostraram diferenças estatísticas entre os grupos (p>0,05). A avaliação da dor através da escala verbal, mostrou vantagem no grupo que utilizou o plasma rico em plaquetas após 24 e 48 horas, uma e três semanas e dois meses de pós-operatório (p<0,05). Conclusões: Da maneira que foi utilizado, o plasma rico em plaquetas não se mostrou efetivo para reduzir sangramento ou melhorar a função do joelho após a artroplastia em comparação aos controles. Houve vantagem na escala verbal de dor pós-operatória...

Purpose: To assess, through a clinical study, randomized, controlled ande singleblinded, the effectiveness of platelet-rich plasma in healing, pain and hemostasis after a total knee arthroplasty. Methods: 40 patients, that would be submitted to total knee arthroplasty, were selected and randomized. In 20 of these was applied platelet-rich plasma before the closure of the joint capsule. Hemoglobin and hematocrit levels were measured in the preoperative, after 24 and 48 hours of surgery. The WOMAC questionnaire and verbal pain scale were applied, measures of the range of motion of the knee were performed until the second postoperative month. Statistical analysis compared the results in order to prove if there is a difference between the groups at each time of evaluation times. Results: Hemoglobin and hematocrit levels performed preoperatively, after 24 and 48h of surgery showed no significant differences between groups (p>0,05). The WOMAC questionnaire and the measures of range of motion in the preoperative and even in the first two months also showed no statistic differences between groups (p>0,05). Pain assessement through verbal scale showed benefit in the group using platelet-rich plasma after 24 and 48 hours, one to three weeks and two months postoperative (p<0,05). Conclusions: The way it was used, the platelet-rich plasma was not effective for reducing bleeding or improve knee function after arthroplasty compared with controls. There was an advantage in the verbal scale of postoperative pain...

Plasma rico em plaquetas (PRP) aplicado na artroplastia total do joelho / Platelet-rich plasma (PRP) applied in total knee arthroplasty

Avaliar, através de um estudo clinico, randomizado, controlado e cego, a eficácia do plasma rico em plaquetas na cicatrização, dor e hemostasia após artroplastia total do joelho. Metodologia: Foram selecionados 40 pacientes que seriam submetidos a prótese total do joelho e randomizados. Em 20 destes pacientes foi aplicado o plasma rico em plaquetas antes do fechamento da cápsula articular. Foram realizadas dosagens de hemoglobina (mg/dL) e hematócrito (%) no pré-operatório, após 24 e 48 horas da cirurgia. Aplicado o questionário WOMAC, a escala verbal da dor e medidas as amplitudes de movimento do joelho até o 2o mês pós-operatório. A análise estatística comparou os resultados afim de comprovar haver diferença entre os grupos em cada um dos momentos da avaliação. Resultados: Medidas do valor da hemoglobina (mg/dL) e hematócrito (%) realizadas no pré-operatório, após 24 e 48 horas da cirurgia não mostraram diferenças significativas entre os grupos (p>0,05). O questionário WOMAC e a amplitude de movimento medidas no pré-operatorio e até os dois primeiros meses também não mostraram diferenças estatísticas entre os grupos (p>0,05). A avaliação da dor através da escala verbal, mostrou vantagem no grupo que utilizou o plasma rico em plaquetas após 24 e 48 horas, uma e três semanas e dois meses de pós-operatório (p<0,05). Conclusões: Da maneira que foi utilizado, o plasma rico em plaquetas não se mostrou efetivo para reduzir sangramento ou melhorar a função do joelho após a artroplastia em comparação aos controles. Houve vantagem na escala verbal de dor pós-operatória...

Protesis patelofemoral: Resultados preliminares: Experiencia Clinica Las Condes / Patellofemoral prosthesis: Preliminary results: Las Condes Clinic experience

Objetivo: Analizar las prótesis patelofemorales modelo Avon (Stryker) realizadas en nuestro centro clínico, evaluando sus resultados a la fecha. Material y Método: Trabajo descriptivo. Revisión de los pacientes con artrosis patelofemoral de la rodilla en los que se realizó una artroplastía patelofemoral con el implante Avon, desde el año 2005 hasta la fecha. Se obtuvieron los datos epidemiológicos, cirugías previas, score preoperatorio (Oxford para prótesis patelofemoral, puntaje máximo 48 puntos) y score post-operatorio (encuesta personal o telefónica). Resultados: Durante el periodo se realizaron 30 implantes en 26 pacientes. El rango de edad fue de 37 a 85 años, promedio de 61 años. La distribución por sexo mostró una mayor frecuencia de mujeres (23 mujeres v/s 3 hombres). El seguimiento es de 35 a 6 meses con un promedio de 25 meses. El score pre-opeeratorio fue de 17-33 pts con un promedio de 24 pts. El score post-operatorio promedio fue de 45 puntos. Un caso requirió una artroscopia a los 6 meses post-operatorio debido a una sinovitis. Hasta el momento no hay revisiones. Conclusiones: El grupo analizado muestra un seguimiento corto, no obstante, los resultados a corto plazo son satisfactorios, con un significativo alivio de la sintomatología. Nuestros resultados son concordantes con la literatura. Consideramos que la prótesis patelofemoral es una alternativa viable para nuestros pacientes que presenta una artrosis limitada a la articulación patelofemoral.

Evaluación del componente patelar en artroplastía total de rodilla / Evaluation of patellar resurfacing in total knee arhtroplasty

Ever since the first Total Knee Arthroplasty was made to our present times, a point that still generates controversy is, if the accomplishment of patellar resurfacing will take to a higher global rate of complications. It was the final objective of our work to analyze clinically and radiologically, in addition to satisfaction degree and quality of life surveys, the patellar resurfacing in a sample of total knee arthroplasty made in our center. We can conclude that in our experience, the patellar resurfacing has a low incidence of complications, which do not affect in a significant way the quality of life of the patients carrying on a total knee arthroplasty, which justifies this procedure absolutely.

Desde que se realizan las Artroplastías Totales de Rodilla hasta la fecha, un punto que genera controversia, es, si la realización de un componente protésico patelar llevará a una mayor tasa global de complicaciones. Es por eso que el objetivo de nuestro trabajo fue analizar clínica y radiológicamente, además de encuestas del grado de satisfacción, el componente de recubrimiento patelar en una muestra de las artroplastías totales de rodilla realizadas en nuestro centro. Se concluye que en nuestra experiencia, el uso de recubrimiento patelar tiene una baja incidencia de complicaciones, las cuales no afectan de manera significativa la calidad de vida de los pacientes con artroplastía total de rodilla, lo que justifica plenamente su utilización.