Renal Adverse Events Associated With Ibuprofen Treatment After Hip and Knee Arthroplasties-A Protocol for the Preplanned Substudy of the PERISAFE Trial.

Update This article was updated on February 6, 2019, because of a previous error. On page 105, in the subsection titled “Outcomes and Design” the sentence that had read “Furthermore, in a retrospective review, Houdek et al. 48 , at a mean follow-up of 8 years, demonstrated improved survivorship of 9,999 metal-backed compared with 1,645 all-polyethylene tibial components, over all age groups and most BMI categories” now reads “Furthermore, in a retrospective review, Houdek et al. 48 , at a mean follow-up of 8 years, demonstrated inferior survivorship of 9,999 metal-backed compared with 1,645 all-polyethylene tibial components, over all age groups and most BMI categories.” An erratum has been published: J Bone Joint Surg Am. 2019 Mar 20;101(6):e26.

Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended for pain treatment after elective hip and knee arthroplasties. However, evidence regarding the incidence of adverse effects with short-term NSAID treatment following surgery is limited. We, therefore, aim to assess the adverse effects with an eight-day postoperative treatment with ibuprofen after elective hip and knee arthroplasties. PERISAFE is a randomized, placebo-controlled, blinded multicenter trial with 90-day and one-year follow-up. Eligible patients undergoing elective hip or knee arthroplasty are allocated 1:1 to either ibuprofen 400 mg ×3/day or identical placebo ×3/day for eight days after surgery. The primary outcome is a composite of either death, acute myocardial infarction, stroke, pulmonary embolism, deep venous thrombosis, renal failure, major bleeding, re-operation, gastrointestinal ulcer, or readmission within 90 days postoperatively. Secondary outcomes are hospital-free days within 90 days postoperatively, a composite of ibuprofen and opioid-related adverse reactions based on eight-day postoperative diary, and health related quality of life after 90 days postoperatively. A total of 2904 patients are needed to demonstrate a relative risk reduction of 33% in the placebo group, accepting a risk of type I error of 5% and type II error of 20% and a proportion of serious adverse events in the ibuprofen group of 8%. The primary analysis will be in the modified intention-to-treat population. The trial is approved by the Danish Medicine Agency and the Research Ethics Committee (EU CT no. 2022-502, 502-32-00). We plan to submit for publication in a major international peer-reviewed journal and present results at scientific meetings.

Non-steroidal Anti-inflammatory drugs (NSAIDs) are effective in reducing acute postoperative pain. However, it is currently unknown what type, dosage, and duration of NSAID are used following primary total hip and knee arthroplasties. We aimed to investigate the use of NSAID following total hip and knee arthroplasties in Denmark, describe general postoperative analgesic regimens, and assess clinicians' attitudes towards NSAID treatment. We conducted a web-based survey distributed to local clinicians responsible for total hip and knee arthroplasties in all public Departments of Orthopedic Surgery in Denmark. The survey focused on standard perioperative treatment practices, and in particular the use of NSAIDs. Of the 40 surgeons invited, 98% responded. The majority (37 of 39, 95%) reported NSAIDs as part of standard analgesic regimes after primary total hip and knee arthroplasties. Ibuprofen was the most commonly used NSAID postoperatively (26 of 37, 70%), typically administered at 1200 mg/day (20 of 26, 77%). The median duration of treatment was 8 days (interquartile range (IQR) 6-12) for total hip arthroplasties and 14 days (IQR 10-14) for total knee arthroplasties. However, there were significant variations between hospitals and regions. Multimodal analgesic treatment using paracetamol, NSAIDs, and opioids was the most common analgesia following total hip and knee arthroplasties. Nine of 38 (24%) were concerned regarding daily clinical treatment with NSAID. NSAIDs, especially ibuprofen, are routinely recommended as part of multimodal therapy for postoperative pain after primary total hip and knee arthroplasties in Denmark. The standard dose is 1200 mg/day, with a median treatment duration of 8 days for total hip arthroplasties and 14 days for total knee arthroplasties, though practices vary across different hospitals and regions.

An integrative review of multimodal pain management on patient recovery after total hip and knee arthroplasty

In this series, we examined analgesia and side effects of intrathecal morphine sulfate (ITMS) after hip and knee arthroplasty over a dose range of 0.0-0.3 mg. Eighty patients undergoing hip (n = 40) or knee (n = 40) arthroplasty were randomized to receive ITMS (0.0, 0.1, 0.2, or 0.3 mg). A patient-controlled analgesia (PCA) device provided free access to additional analgesics. Morphine use, pain relief, and side effects were recorded for 24 h. Data were analyzed with analysis of variance and linear regression. After hip arthroplasty, morphine use was less in patients receiving 0.1, 0.2, or 0.3 mg of ITMS than in control patients (P < 0.05). After knee arthroplasty, ITMS did not reduce postoperative morphine requirements. Nausea and vomiting and the incidence of oxygen saturation <93% were similar in all groups. Pruritus was more common after ITMS. Patients receiving 0.2 or 0.3 mg of ITMS were more satisfied with their pain control than those receiving 0.0 or 0.1 mg after both hip and knee arthroplasty. Analgesic needs are greater after knee arthroplasty than after hip arthroplasty. We conclude that combining small-dose (0.2 mg) ITMS with PCA morphine provides good to excellent pain control in most patients after total hip or knee arthroplasty. However, PCA morphine use was reduced by the addition of ITMS only after hip arthroplasty. This series examined the need for supplemental analgesics, the quality of analgesia, and the incidence of side effects with intrathecal morphine sulfate (ITMS) for analgesia after hip and knee arthroplasty. Analgesic needs are greater after knee arthroplasty than hip arthroplasty. Combining small-dose (0.2 mg) ITMS with standard doses of PCA morphine provided good to excellent pain control in most patients and reduced patient-controlled analgesia morphine use after hip, but not knee, arthroplasty.

Objective To investigate the relationship between discharge C-reactive protein (CRP) level of osteoarthritis (OA) patients and periprosthetic joint infection (PJI) after primary unilateral total hip arthroplasty (THA) or total knee arthroplasty (TKA). Methods From January 2013 to December 2015, 480 OA patients receiving primary unilateral THA or TKA were admitted in department of Orthopedics of Zhongda Hospital Southeast University. The inclusion criteria were normal CRP level before operation, and exclusion criteria were preoperative history of infection, diabetes mellitus, malignant tumors, ect. The patients were divided into the high CRP group (273 cases) and the normal CRP group (207 cases) based on serum CRP level at discharging. Both groups were matched for known confounding factors such as sex, age and discharge time. The hemogram, temperature and wounds of all the patients were normal at discharge, and no antibiotic or NSAIDs were used after discharge. Cases and occurrence time of PJI were recorded during the follow-up. The measurement date were tested by t test, and the incidence of PJI was compared by chi-square test or Fisher’s exact probability method. Results Both groups were matched for known confounding factors such as sex, age and discharge time. A total of 415 cases were followed-up after discharge, ranging from 13 to 26 months (18±3) months on average. Although there were three and two PJI cases in both groups respectively at the last follow-up, the results indicated no significant difference in incidence rate of PJI (χ2=0.023, P>0.05). The occurrence time of PJI in the high CRP group was shorter than that in the normal CRP group obviously, and the higher CRP level at discharge, the shorter occurrence time of PJI. Conclusion There may be no relationship between discharge CRP level of OA patients and incidence rate of PJI after primary unilateral THA or TKA, however, the patients with high discharge C-reactive protein level should be closely followed up. Key words: C-reactive protein; Arthroplasty, replacement; Hip; Knee; Osteoarthritis; Joint prosthesis; Infection

Routine Prescription of Proton Pump Inhibitors in the Perioperative Period is Associated With Decreased Rates of 2-Year Revision Surgery After Total Hip and Knee Arthroplasty

Although guidelines now allow the use of aspirin as an alternative to anticoagulants for venous thromboembolism prophylaxis after knee or hip arthroplasty, there is limited data on contemporary use and outcomes with aspirin. To describe the use of pharmacologic thromboprophylaxis and to assess venous thromboembolic risk with aspirin compared with anticoagulation after knee or hip arthroplasty. Retrospective cohort study using data from the US MedAssets database. Adults with a principal discharge diagnosis of knee or hip arthroplasty between January 1, 2013, and December 31, 2014. We identified charges for medications used for thromboprophylaxis within 7days after the index surgery from billing records. The primary outcome was postoperative venous thromboembolism identified by International Classification of Diseases, 9th edition codes, from the index hospitalization, rehospitalization within 30days, or during an outpatient visit within 90days postoperatively. We compared postoperative thromboembolic risk in patients receiving aspirin-only and those receiving anticoagulants using propensity score-adjusted multivariable logistic regression models. We identified 74,234 patients with knee arthroplasty and 36,192 with hip arthroplasty who received pharmacologic thromboprophylaxis. Aspirin-only was used in 27.9% of all patients, while 24.2% and 24.1% received warfarin or enoxaparin as prophylactic monotherapy, respectively. Postoperative venous thromboembolism occurred in 495 (0.67%) patients undergoing knee arthroplasty and 145 (0.40%) undergoing hip arthroplasty. Aspirin-only was not related to increased odds of postoperative venous thromboembolism compared with anticoagulants in multivariable adjusted analyses (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.56-0.87, and OR 0.93; 95% CI, 0.62-1.38 for knee or hip arthroplasty, respectively). More than a fourth of all patients received aspirin as the sole antithrombotic agent after knee or hip arthroplasty. Postoperative thromboprophylaxis with aspirin-only was not associated with a higher risk of postoperative venous thromboembolism compared with anticoagulants after hip or knee arthroplasty.

Multicenter Randomized Controlled Trial Comparing Early Versus Late Aquatic Therapy After Total Hip or Knee Arthroplasty

With the rapid development of an aging society, the number of Total Hip and Knee Arthroplasty continues to increase, which makes the country medical insurance funds and elderly patients burden with medical treatment increasing. The early ambulation of postoperative patients with Total Hip and Knee Arthroplasty can effectively shorten the length of hospital stay, save hospitalization costs, and improve joint function. Therefore, this article reviews the concept, status, implementation obstacles, promotion measures and other aspects of early ambulation of postoperative patients undergoing Total Hip and Knee Arthroplasty, with a view to provide theoretical reference for the development of standar-dized and efficient early ambulation of medical personnel. Key words: Joint arthroplasty; Total hip arthroplasty; Total knee arthroplasty; Early ambulation

Little is known about the incidence and time course of clinical thromboembolic events after total hip or knee arthroplasty, particularly after hospital discharge. We used a linked hospital discharge database provided by the State of California to identify cases diagnosed as having deep vein thrombosis or pulmonary embolism within 3 months of unilateral total hip or knee arthroplasty. Also, we surveyed orthopedic surgeons to estimate the frequency of postoperative thromboprophylaxis during July 1991 through June 1993. Medical charts were audited to determine the accuracy of the coded records. Among 19,586 primary hip and 24,059 primary knee arthroplasties, the cumulative incidence of deep vein thrombosis or pulmonary embolism within 3 months of surgery was 556 (2.8%) after hip arthroplasty and 508 (2.1%) after knee arthroplasty. The diagnosis of thromboembolism was made after hospital discharge in 76% and 47% of the total hip and total knee arthroplasty cases, respectively (P<.001), with a median time of diagnosis of 17 days and 7 days after surgery, respectively (P<.001). Questionnaire results indicated that 95% of all cases received thromboprophylaxis and that the frequency, type, and duration of thromboprophylaxis was virtually identical after hip and knee arthroplasty. There is a difference in the temporal patterns of clinically symptomatic thromboembolic complications after total hip and total knee arthroplasty, suggesting differences in pathogenesis or natural history. The findings suggest that to further reduce thromboembolic outcomes, earlier, more intense prophylaxis may be needed for total knee arthroplasty, and more prolonged prophylaxis may be required after total hip arthroplasty.

Recovery from hip and knee arthroplasty: Patients' perspective on pain, function, quality of life, and well-being up to 6 months postoperatively

Recent case reports have shown that over-the-counter (OTC) analgesics, which are generally considered to be a safe treatment for minor aches and pains and fever, may cause adverse renal effects. Many renal syndromes induced by nonsteroidal antiinflammatory drugs (NSAIDs) can be attributed to prostaglandin inhibition. Fluid and electrolyte disturbances, acute renal failure, and acute interstitial nephritis also occur predominantly with NSAIDs. Acetaminophen lacks significant peripheral prostaglandin inhibition and may be a preferred first-line agent, particularly in patients susceptible to the induction of renal impairment. Apart from obvious clinical overdosage situations, limited reports of adverse renal effects exist with acetaminophen. Some studies have reported an association between analgesic nephropathy, one of the most severe analgesic-related adverse renal effects, and long-term abuse of phenacetin, acetaminophen, aspirin, ibuprofen, analgesic combinations, or other NSAIDs, although for some of these agents, this relationship is controversial. The overall risk for serious renal effects with OTC analgesics appears to be low, but given the accessibility and vast number of persons taking these agents, the absolute number of patients affected may be substantial. Therefore, it is important that healthcare providers recognize the risk factors for adverse analgesic-related renal effects.

Arthroplasty is indicated for patients with rheumatoid arthritis (RA) who experience significant joint damage, including bone erosions, cartilage degradation and joint deformities. However, studies on its associations with all-cause mortality, cardiovascular disease (CVD), and venous thromboembolism (VTE) among patients with RA are scarce. Our aim was to evaluate the relation of knee arthroplasty or hip arthroplasty to all-cause mortality, relative risk of CVD and incident VTE among patients with RA. We included patients with RA (ages≥20 years) from a large United Kingdom primary care database (i.e., IQVIA Medical Research Database). The primary outcome was all-cause mortality (n = 4,774 for knee arthroplasty, n = 3,362 for hip arthroplasty). The secondary outcomes included incident CVD (n = 4,350 for knee arthroplasty, n = 2,390 for hip arthroplasty) and incident VTE (n = 4,574 for knee arthroplasty, n = 3,174 for hip arthroplasty). We conducted propensity score-matched cohort studies to compare the risks of each outcome between subjects with and without knee arthroplasty (n = 2,387 each) and those with and without hip arthroplasty (n = 1,681 each), respectively. We found that subjects with knee arthroplasty had a 23% lower risk of mortality than those without knee arthroplasty (HR: 0.77, 95%CI: 0.65–0.90). Similarly, a lower, albeit non-statistically significant, risk of mortality was observed among subjects with hip arthroplasty than those without arthroplasty (HR: 0.87, 95%CI: 0.73–1.04). Compared with those without arthroplasty, subjects with knee or hip arthroplasty had a lower risk of CVD. The corresponding HRs were 0.86 (95%CI: 0.73–1.01) and 0.84 (95%CI: 0.69–1.02), respectively. Both subjects with knee or hip arthroplasty showed a higher risk of VTE than their counterparts (HR for knee arthroplasty: 1.63 [95%CI: 1.23–2.17]; HR for hip arthroplasty: 2.19 [95%CI: 1.54–3.11]). The associations of arthroplasty with the risks of mortality, CVD and VTE were generally consistent across strata of age and sex, with HR ranges from 0.71–3.75 for knee arthroplasty and 0.66–3.36 for hip arthroplasty. In this large population-based cohort of patients with RA, knee arthroplasty was associated with a lower risk of all-cause mortality, while both knee and hip arthroplasty were associated with a higher risk of VTE. No significant associations were observed with CVD. These findings highlight potential long-term benefits and risks of joint replacement in RA, but given the observational design and possibility of residual confounding, the results should be interpreted as associations rather than causal effects. Further studies are warranted to confirm these observations and to better understand the mechanisms underlying these associations.

Do clinical or patient characteristics influence return to driving a car after a total knee or hip arthroplasty? a systematic review of the literature