Primary Unilateral Total Knee Arthroplasty Research Articles

Effect of intraoperative cold solution irrigation to reduce postoperative pain in knee osteoarthritis patients who underwent unilateral primary total knee arthroplasty: a double-blinded randomized controlled trial

PurposeTo compare the postoperative pain score, opioid consumption, and blood loss in knee osteoarthritis patients who underwent unilateral primary total knee arthroplasty with and without intraoperative cold solution irrigation.MethodIn total, 70 knee osteoarthritis patients were randomly included in the study and allocated into 2 groups. The first group was irrigated intraoperatively with a cold solution and the second group was irrigated intraoperatively with a room-temperature solution.ResultsThe cold solution group showed significantly lower pain scores (numerical rating scale, NRS) at 28 h postoperatively (p = 0.047). There were no significant differences in opioid consumption or blood loss between the groups.ConclusionsIntraoperative cold solution irrigation in unilateral primary total knee arthroplasty patients may provide the benefit of early postoperative pain reduction for up to 28 h but has no effect in terms of reducing opioid consumption or blood loss.Trial registrationThe trial was registered in the Thai Clinical Trials Registry (TCTR) Trial registration number ID: TCTR20200706001 on 06/07/2020.

Efficacy and Safety of Bone Wax Application at Different Time Points to Reduce Postoperative Blood Loss in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial.

In addition to the surface hemorrhage of cancellous bone after large-area osteotomy, the intramedullary hemorrhage after the reamed knee joint is also a major cause of postoperative bleeding after total knee arthroplasty (TKA). This study evaluated the efficacy and safety of bone wax application at different time points of prone hemorrhage to reduce perioperative blood loss. From August 2023 to December 2023, 150 patients undergoing primary unilateral TKA were included in this prospective, randomized controlled trial, patients were randomly divided into three groups: group A, after autogenous osteotomy plug was used to fill the femoral medullary cavity, the residual space was sealed with bone wax and the exposed cancellous bone surface around the prosthesis was coated with bone wax after the prosthesis adhesion; group B, only the exposed cancellous bone surface around the prosthesis was coated with bone wax; and group C, no bone wax was used. The primary outcome was total perioperative blood loss. Secondary outcomes included occult blood loss, postoperative hemoglobin reduction, blood transfusion rate, lower limb diameter, and knee function, while length of hospital stay was recorded. Tertiary outcomes included the incidence of postoperative related adverse events. The total blood loss in group A (551.5 ± 224.5 mL) and group B (656.3 ± 267.7 mL) was significantly lower than that in group C (755.3 ± 248.3 ml, p < 0.001), and the total blood loss in group A was also lower than that in group B (p < 0.05). There were also significant differences in the reduction of hemoglobin level and hidden blood loss among the three groups (p < 0.05). However, there was no significant improvement in postoperative lower limb swelling, knee joint activity and hospitalization time; there was no significant difference in the incidence of complications such as thromboembolism. The use of bone wax in TKA can safely and effectively reduce perioperative blood loss and hemoglobin drop rate, and multiple use at time points during the operation when blood loss is prone to occur can produce more significant hemostatic effect.

Continued stepped care model improves early-stage self-report quality of life and knee function after total knee arthroplasty.

The Stepped Care Model (SCM) is an evidence-based treatment approach that tailors treatment intensity based on patients' health status, aiming to achieve the most positive treatment outcomes with the least intensive and cost-effective interventions. Currently, the effectiveness of the Stepped Care Model in postoperative rehabilitation for TKA (Total Knee Arthroplasty) patients has not been reported. The present study aimed to investigate whether the stepped care model could improve early-stage self-report quality of life and knee function after total knee arthroplasty via a prospective randomized controlled design. It was a mono-center, parallel-group, open-label, prospective randomized controlled study. Patients who aging from 60-75 years old as well as underwent unilateral primary total knee arthroplasty due to end-stage knee osteoarthritis between 2020.06 to 2022.02 were enrolled. Participants were randomized and arranged into two groups in a 1:1 allocation. The control group was given traditional rehabilitation guidance, while the stepped care model group was given continued stepped care. Hospital for special surgery knee score, daily living ability (ADL), knee flexion range, and adverse events at 1, 3, and 6 months after total knee arthroplasty were recorded. 88 patients proceeded to the final analysis. There was no significant difference of age, gender, length of stay, BMI, and educational level between the two groups at the baseline. After specific stepped care model interventions, patients showed significant improvements in HHS in 1 month (85.00 (82.25, 86.00) vs. 80.00 (75.00, 83.00), p< 0.001), 3 months (88.00 (86.00, 92.00) vs. 83.00 (76.75, 85.00), p< 0.001), and 6 months (93.00 (90.25, 98.00) vs. 88.00 (84.25, 91.75), p< 0.001) when compared with the control group. Similar results were also found in both daily living ability and knee flexion angle measurements. No adverse event was observed during the follow-up. The present study found that the stepped care model intervention significantly improved early-stage knee function and self-reported life quality after total knee arthroplasty due to knee osteoarthritis. Female patients and those less than 70 years old benefit more from the stepped care model intervention after total knee arthroplasty.

MT44 Handheld Robotically Assisted Primary Unilateral Total Knee Arthroplasty (R-TKA) Demonstrates Lower Short-Term Costs and Length of Stay Compared to Conventional Instrumentation TKA (C-TKA)

MT44 Handheld Robotically Assisted Primary Unilateral Total Knee Arthroplasty (R-TKA) Demonstrates Lower Short-Term Costs and Length of Stay Compared to Conventional Instrumentation TKA (C-TKA)

Evaluation of efficacy and safety of perioperative tranexamic acid during Primary Total Knee Arthroplasty: A randomized, Clinical trial.

Primary total knee arthroplasty (TKA) is the gold standard treatment for degenerative joint disease, but it carries a significant risk of blood loss that may require transfusion. Various techniques are implemented to reduce the possibility of the need for allogeneic blood transfusion (ABT). To this end, this study aims to assess the effectiveness of tranexamic acid (TXA) in decreasing blood loss following primary TKA. This study is a randomized controlled study of 100 cases of primary total knee arthroplasty conducted in Damascus from July 2021 to September 2022, followed up with every patient for six months. The patients were randomized into two groups. We compared intraoperative, postoperative, total, and hidden blood loss and perioperative complications. We observed a statistically significant difference between the two groups in total calculated, hidden, and postoperative blood loss. However, this difference does not seem clinically significant, as we didn't find a significant difference in allogeneic blood transfusion between the groups. Regarding complications, the TXA group had five cases of superficial wound infection and six cases of deep venous thrombosis. In contrast, the control group had eight cases of superficial wound infection and five cases of deep venous thrombosis. Our study suggests that the role of TXA in primary unilateral total knee arthroplasty in the hands of an experienced surgeon might be overrated. The reduced blood loss did not seem to have clinical importance and didn't affect the transfusion rates.

Normative Values for Daily Functional Recovery Patterns Following Total Knee Arthroplasty

BackgroundWearable devices provide the ability for clinical teams to continuously monitor patients’ rehabilitation progress with objective data. Understanding expected recovery patterns following total knee arthroplasty (TKA) enables prompt identification of patients failing to meet these milestones. The aim of this study was to establish normative values for daily functional recovery in the first 6 weeks after TKA using a wearable device. MethodsThis prospective study included patients who underwent TKA between 2020 and 2023, treated by 11 surgeons from 8 institutions. Eligible participants were aged 18 or older, had a primary unilateral TKA, and owned a smartphone. Knee range of motion, total daily steps, cadence, and device usage were measured continuously over 6 weeks. Statistical analysis included analysis of variance using post hoc Tukey honest significant difference tests. ResultsThe cohort of 566 participants had a mean age of 65 and 69 for men and women, respectively (range, 50 to 80). Women comprised 61% (n = 345) of study participants. There were 82% of women and 90% of men who had a body mass index > 30. The average daily wear time of the device was 12 hours (±4) for a total of 45 days (±27). Recovery was nonlinear, with the greatest gains in the first 3 weeks postsurgery for all metrics. Men demonstrated greater total daily step counts and cadence when compared to women. Obese patients demonstrated poorer performance when compared to lower body mass index patients. ConclusionsTo our knowledge, this study presents the first normative data for tracking daily functional recovery in TKA patients using wearable sensors. Standardizing the TKA recovery timeline allows surgeons to isolate factors affecting patients’ healing processes, accurately counsel them preoperatively, and intervene more promptly postoperatively when rehabilitation is not within standard recovery parameters.

J-shaped association of operation duration and blood transfusion risk in patients undergoing primary total knee arthroplasty.

Blood transfusion is a common perioperative complication of primary total knee arthroplasty (TKA) that can lead to adverse outcomes, prolonged hospital stays, and increased medical costs. The purpose of our study was to explore the risk factors for blood transfusion and to establish whether operation duration is independently related to blood transfusion risk in patients undergoing primary TKA after adjusting for other covariates. This was a secondary analysis of data from a retrospective cohort study involving patients who underwent primary TKA in Singapore. The patients' baseline data, comorbidity, and surgical characteristics were collected. The independent variable was operation duration and the dependent variable was blood transfusion events. Patients were divided into three groups according to operation durations (90 and 120min). Univariate logistic regression was used to explore the risk factors associated with blood transfusion after primary TKA. Multivariate analysis was used to assess the independent effect of operation duration on blood transfusion risk after adjusting for other covariates. Additionally, we performed subgroup analyses to identify specific groups, test the robustness of the relationships, and explore whether there were interactions between the different variables. Furthermore, restricted cubic splines (RCS) were used to identify the relationship between the two variables. A total of 2,562 patients were included in the study, of whom 136 (5.61%) had a transfusion event. Operation durations were 95.55 ± 36.93 and 83.86 ± 26.29min for blood transfused and non-transfused patients, respectively. Univariate logistic regression analysis showed that age, BMI, ASA status, Hb level, OSA, CHF, creatinine level > 2mg/dL, and anaesthesia type were risk factors for blood transfusion. After adjusting for all covariates, multivariate logistic regression models showed that operation duration was positively associated with blood transfusion risk (odds ratio [OR] = 1.87, 95% CI = 1.174-2.933, P = 0.007). Compared to patients with an operation duration of less than 90min, those with an operation duration of more than 120min had a 2.141-fold increased risk of blood transfusion (OR = 2.141, 95% CI = 1.035-4.265, P = 0.035). Stratified analysis results showed that the association persisted in patients aged > 50years, Chinese, BMI > 30kg/m 2, Hb level > 11g/dL, ASA status levels 2 and 3, general anaesthesia, and unilateral primary TKA. A non-linear (P-non-linear = 0.30) and J-shaped relationship was identified. The risk of transfusion increased as the operation duration decreased or exceeded the inflection point (73.2min). Our study demonstrated a non-linear and J-shaped relationship between operation duration and blood transfusion events in patients undergoing primary TKA. Blood transfusion risk was the lowest when the operation duration was 73.2min. A shorter operation duration implies irregular surgical procedures and incomplete intraoperative haemostasis, leading to increased perioperative blood loss and blood transfusion. These results will be useful for clinical decision-making.

Robotic-assisted total knee arthroplasty is associated with the use of thinner polyethylene liners compared to navigation-guided and manual techniques.

The purpose of this study was to examine the effects of intraoperative technology use on the rate of using polyethylene liners 15 mm or greater during primary total knee arthroplasty (TKA). There were 103,295 implants from 16,386 primary unilateral TKAs performed on 14,253 patients at a single institution between 1 January2018, and 30 June2022, included in the current study. Robotic assistance and navigation guidance were used in 1274 (8%) and 8345 (51%) procedures, respectively. The remaining 6767 TKAs (41%) were performed manually. Polyethylene liners were manually identified and further subcategorised by implant thickness. Patients who underwent robotic-assisted TKA were younger (p < 0.001) and more likely to be male (p < 0.001) compared to patients who underwent navigation-guided or manual TKAs. Average polyethylene liner thickness was similar between groups (10.5 ± 1.5 mm for robotic-assisted TKAs, 10.9 ± 1.8 mm for navigation-guided TKAsand 10.8 ± 1.8 mm for manual TKAs). The proportions of polyethylene liners 15 mm or greater used were 4.9%, 3.8%and 1.9% for navigation-guided, manual and robotic-assisted procedures, respectively (p < 0.001). Multivariate regression analyses demonstrated that navigation-guided (odds ratio [OR]: 2.6, 95% confidence Interval [CI]: [1.75-4.07], p < 0.001) and manual (OR: 2.0, 95% CI: [1.34-3.20], p = 0.001) procedures were associated with an increased use of polyethylene liners 15 mm or greater. Robotic-assisted TKA was associated with a lower proportion of polyethylene liners 15 mm or greater used compared to navigation-guided and manual TKA. These findings suggest that robotic assistance can reduce human error via a more precise cutting system, limit over-resection of the tibia and flexion-extension gap mismatchand ultimately allow for more appropriately sized implants. Level III, retrospective cohort study.

Efficacy of adding infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) to adductor canal block and local infiltration analgesia in total knee arthroplasty: A retrospective cohort study.

Local infiltration analgesia (LIA), adductor canal block (ACB), and infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) are popular multimodal analgesia techniques used during total knee arthroplasty (TKA). This study aimed to explore the efficacy of adding the IPACK technique to ACB and LIA in patients undergoing TKA. In this retrospective cohort study, patients who underwent primary unilateral TKA were divided into two groups based on their date of admission. Sixty-three patients underwent IPACK, ACB and LIA (IPACK group) during surgery, while 60 patients underwent ACB and LIA (control group). The primary outcome was the postoperative administration of morphine hydrochloride as a rescue analgesic. Secondary outcomes included time to first rescue analgesia, postoperative pain assessed using the visual analog scale (VAS), functional recovery assessed by knee range of motion and ambulation distance, time until hospital discharge, and complication rates. The two groups were similar in average postoperative 0-to-24-h morphine consumption (11.8mg for the control group vs 12.7mg for the IPACK group, p = .428) and average total morphine consumption (18.2mg vs 18.0mg, p = .983) during hospitalization. There were also no significant differences in the secondary outcomes. The addition of IPACK to ACB and LIA did not provide any clinical analgesic benefits. Orthopedic surgeons and anesthesiologists are justified in using ACB and LIA without IPACK for TKA.

Nanotechnology for Pain Management.

Introduction: In the context of the current opioid crisis, non-pharmacologic approaches to pain management have been considered important alternatives to the use of opioids or analgesics. Advancements in nano and quantum technology have led to the development of several nanotransporters, including nanoparticles, micelles, quantum dots, liposomes, nanofibers, and nano-scaffolds. These modes of nanotransporters have led to the development of new drug formulations. In pain medicine, new liposome formulations led to the development of DepoFoam™ introduced by Pacira Pharmaceutical, Inc. (Parsippany, NJ, USA). This formulation is the base of DepoDur™, which comprises a combination of liposomes and extended-release morphine, and Exparel™, which comprises a combination of liposomes and extended-release bupivacaine. In 2021, Heron Therapeutics (San Diego, CA, USA) created Zynrelef™, a mixture of bupivacaine and meloxicam. Advancements in nanotechnology have led to the development of devices/patches containing millions of nanocapacitors. Data suggest that these nanotechnology-based devices/patches reduce acute and chronic pain. Methods: Google and PubMed searches were conducted to identify studies, case reports, and reviews of medical nanotechnology applications with a special focus on acute and chronic pain. This search was based on the use of keywords like nanotechnology, nano and quantum technology, nanoparticles, micelles, quantum dots, liposomes, nanofibers, nano-scaffolds, acute and chronic pain, and analgesics. This review focuses on the role of nanotechnology in acute and chronic pain. Results: (1) Nanotechnology-based transporters. DepoDur™, administered epidurally in 15, 20, or 25 mg single doses, has been demonstrated to produce significant analgesia lasting up to 48 h. Exparel™ is infiltrated at the surgical site at the recommended dose of 106 mg for bunionectomy, 266 mg for hemorrhoidectomy, 133 mg for shoulder surgery, and 266 mg for total knee arthroplasty (TKA). Exparel™ is also approved for peripheral nerve blocks, including interscalene, sciatic at the popliteal fossa, and adductor canal blocks. The injection of Exparel™ is usually preceded by an injection of plain bupivacaine to initiate analgesia before bupivacaine is released in enough quantity from the depofoarm to be pharmacodynamically effective. Finally, Zynrelef™ is applied at the surgical site during closure. It was initially approved for open inguinal hernia, abdominal surgery requiring a small-to-medium incision, foot surgery, and TKA. (2) Nanotechnology-based devices/patches. Two studies support the use of nanocapacitor-based devices/patches for the management of acute and chronic pain. A randomized study conducted on patients undergoing unilateral primary total knee (TKA) and total hip arthroplasty (THA) provided insight into the potential value of nanocapacitor-based technology for the control of postoperative acute pain. The results were based on 2 studies, one observational and one randomized. The observational study was conducted in 128 patients experiencing chronic pain for at least one year. This study suggested that compared to baseline, the application of a nanocapacitor-based Kailo™ pain relief patch on the pain site for 30 days led to a time-dependent decrease in pain and analgesic use and an increase in well-being. The randomized study compared the effects of standard of care treatment to those of the same standard of care approach plus the use of two nanocapacitor-based device/patches (NeuroCuple™ device) placed in the recovery room and kept in place for three days. The study demonstrated that the use of the two NeuroCuple™ devices was associated with a 41% reduction in pain at rest and a 52% decrease in the number of opioid refills requested by patients over the first 30 days after discharge from the hospital. Discussion: For the management of pain, the use of nano-based technology has led to the development of nano transporters, especially focus on the use of liposome and nanocapacitors. The use of liposome led to the development of DepoDur™, bupivacaine Exparel™ and a mixture of bupivacaine and meloxicam (Zynrelef™) and more recently lidocaine liposome formulation. In these cases, the technology is used to prolong the duration of action of drugs included in the preparation. Another indication of nanotechnology is the development of nanocapacitor device or patches. Although, data obtained with the use of nanocapacitors are still limited, evidence suggests that the use of nanocapacitors devices/patches may be interesting for the treatment of both acute and chronic pain, since the studies conducted with the NeuroCuple™ device and the based Kailo™ pain relief patch were not placebo-controlled, it is clear that additional placebo studies are required to confirm these preliminary results. Therefore, the development of a placebo devices/patches is necessary. Conclusions: Increasing evidence supports the concept that nanotechnology may represent a valuable tool as a drug transporter including liposomes and as a nanocapacitor-based device/patch to reduce or even eliminate the use of opioids in surgical patients. However, more studies are required to confirm this concept, especially with the use of nanotechnology incorporated in devices/patches.

Significant improvement in locomotive functions after total knee arthroplasty but worse than those of independent ambulatory community dwellers

PurposeThis study investigated the adequacy of improvements in locomotive syndrome (LS) and other clinical outcomes after total knee arthroplasty (TKA) for medial knee osteoarthritis. MethodsA total of 74 patients who underwent unilateral primary TKA were evaluated pre-operatively and 3, 6, and 12 months post-TKA using the 25-question Geriatric Locomotive Function Scale (GLFS-25) to evaluate the severity of LS, the Japanese Knee Osteoarthritis Measure (JKOM), the Knee Society Score (KSS), the timed up and go (TUG) test, and range of motion of the knee joint (ROM). The GLFS-25 score and the severity of LS were compared between these patients and independent ambulatory community dwellers (273 males and 477 females). ResultsThe GLFS-25, JKOM, KSS, TUG scores, and ROM significantly improved post-operatively. The pre-operative incidence of LS stage 3, indicating the worst locomotive function, decreased from 81.1% to 24.3% at the final follow-up. However, the median (interquartile range) GLFS-25 score of 13 (6–23) seemed much worse, and the incidence of LS stage 3 of 24.3% seemed much higher even 12 months post-TKA compared with independent ambulatory community dwellers. ConclusionsThe GLFS-25 score and other clinical outcome scales significantly improved after TKA. However, improvements in locomotive functions were not adequate as approximately 25% of patients remained with LS stage 3. Besides ordinary rehabilitation programmes after TKA, some interventions, such as more rigorous muscle exercises, would be necessary to obtain greater improvements in LS.

Comparative effectiveness of combined peri-articular and intra-articular injection versus intravenous and intra-articular injection of tranexamic acid in total knee arthroplasty: a randomized controlled trial study.

Tranexamic acid (TXA) administration is supported by numerous evidence in reducing blood loss after total knee arthroplasty (TKA). The combination of intravenous (IV) and intra-articular (IA) TXA administration revealed good result in blood loss reduction with less evidence of venous thromboembolism event (VTE). Several literature reviews portray that peri-articular (PA) administration yields similar hemostasis in comparison to IV route. However, there is no report on the clinical effect of combining PA + IA TXA in blood loss reduction and its complications, compared to combining IV + IA TXA after TKA. We conducted a double-blind, randomized controlled trial comparing the use of PA + IA TXA administration and IV + IA TXA administration in 70 patients who were scheduled for unilateral primary TKA. Thirty-five patients were assigned for PA + IA injection (Group 1) and anoter 35 patients were assigned for IV + IA injection (Group 2). Primary outcomes included total blood loss at 48h, and the need for blood transfusion. Secondary outcomes included thigh and leg circumference, degree of knee flexion, and postoperative complications. The calculated blood loss at 48h showed no difference between Groups 1 and 2 (617ml vs. 632ml, p = 0.425). The total hemoglobin and hematocrit changes were not different (1.89g/dL vs. 1.97g/dL, p = 0.371 and 5.66% vs. 5.87%, p = 0.391). There was no need for blood transfusion in either group. However, lower thigh swelling was significant in Group 1 (2.15cm vs. 2.79cm, p = 0.04). Leg circumferences at 48h was also lower in Group 1(42.12cm vs. 42.77cm, p = 0.04). There was no significant difference in knee flexion decrease between the two groups (38° vs. 37°, p = 0.425). There were no VTE complications or infections found in either group. Combined PA + IA TXA administration had similar efficacy in blood loss reduction and blood transfusion when compared to combined IV + IA TXA. The first group displayed less soft tissue swelling. The combination of PA + IA TXA administration can be used as an alternative regimen to avoid IV TXA administration.

The ROSA knee robotic system demonstrates superior precision in restoring joint line height and posterior condylar offset compared to conventional manual TKA: a retrospective case–control study

PurposeVariations in total knee arthroplasty (TKA) joint line height may lead to complications such as pain and altered joint mechanics, while posterior condylar offset (PCO) can influence knee stability.MethodsSingle-centre, single-surgeon retrospective analysis from December 2019 to May 2023 investigated primary unilateral TKA (Nexgen Legacy, Zimmer Biomet) in patients with knee osteoarthritis, using ROSA robotic system (raTKA) or conventional manual technique (mTKA). Joint line height and PCO were measured and compared in 182 raTKA and 144 mTKA patients.ResultsThe groups were matched in age (p = 0.847) and sex distribution (p = 0.2). Excellent interobserver agreement (ICC ≥ 0.9). RaTKA mean joint line height difference was − 0.0001 mm (± 3.48, 95% CI − 0.509, 0.509) (p = 0.523), − 0.951 mm for mTKA (± 4.33, 95% CI − 1.664, − 0.237) (p = 0.009). RaTKA mean PCO difference was 0.52 mm (± 2.45, 95% CI 0.160, 0.880) (p = 0.005), 1.15 mm for mTKA (± 4.01, 95% CI – 1.496, 1.818) (p < 0.001). Mean difference in joint line height of 0.95 mm between groups was significant (p = 0.027), and for PCO, it was 0.63 mm, demonstrating tendency towards significance (p = 0.08). Mean absolute value in joint line height difference between groups was not significant (p = 0.235) but highly significant for PCO (p < 0.001).ConclusionThe ROSA knee robotic system can more accurately restore joint line height and PCO compared to conventional manual TKA. The improved degree of precision raTKA offers may be a vehicle for better Patient-Reported Outcome Measures, but further correlational studies are required.

A new dressing system for accelerating wound recovery after primary total knee arthroplasty: a feasibility study.

Currently, postoperative wound infection and poor healing of total knee arthroplasty have been perplexing both doctors and patients. We hereby innovatively invented a new dressing system to reduce the incidence of postoperative wound complications. We enrolled 100 patients who received primary unilateral total knee arthroplasty and then applied the new dressing system. The data collected included the number of dressing changes, postoperative hospital stay, Visual Analogue Scale score (VAS), the Knee Society Score (KSS), the Knee Injury and Osteoarthritis Outcome Score (KOOS), ASEPSIS scores, The Stony Brook Scar Evaluation Scale (SBSES), wound complications, dressing cost, the frequency of shower and satisfaction. Subsequently, a statistical analysis of the data was performed. Our findings demonstrated the average number of postoperative dressing changes was 1.09 ± 0.38, and the average postoperative hospital stay was 3.72 ± 0.98 days. The average cost throughout a treatment cycle was 68.97 ± 12.54 US dollars. Collectively, the results of VAS, KSS, and KOOS revealed that the pain and function of patients were continuously improved. The results of the four indexes of the ASEPSIS score were 0, whereas the SBSES score was 3.58 ± 0.52 and 4.69 ± 0.46 at two weeks and one month after the operation, respectively. We observed no wound complications until one month after the operation. Remarkably, the satisfaction rate of the patients was 91.85 ± 4.99% one month after the operation. In this study, we invented a new dressing system for surgical wounds after total knee arthroplasty and further confirmed its clinical feasibility and safety. ChiCTR2000033814, Registered 13/ June/2020.

EVALUATING THE BLOOD-SPARING EFFICACY AND SAFETY OF TRANEXAMIC ACID IN TOTAL KNEE ARTHROPLASTY

Objectives: Tranexamic acid (TXA) is an antifibrinolytic agent that effectively reduces bleeding both during and after surgery. The purpose of our study was to assess the effectiveness and safety of TXA use in reducing blood loss in uncomplicated primary total knee arthroplasty (TKA) without complications. Methods: This is a prospective, open-label, comparative study that includes patients who are undergoing unilateral primary TKA. The patients were divided into two groups: Group I, which is a control group, did not receive any doses of TXA, and Group II received three doses of intravenous TXA: 15 mg/kg TXA was administered 30 min before incision, followed by post-operative doses of 10 mg/kg TXA at 3 and 6 h. The primary objectives of the study were to measure the total blood loss (TBL) and Hemoglobin (Hb) drop, which were calculated preoperatively and on the third post-operative day. The secondary objectives were to determine transfusion rates, incidences of symptomatic deep vein thrombosis, and thromboembolic events (TE). Results: In this study, a total of 57 patients underwent unilateral TKA. The TBL in Group I was 861.67±167.65 mL, compared to 780.05±158.05 mL in Group II (p&lt;0.001). The study also found that the Hb drop was significantly lower (2.78±0.36 vs. 2.3±0.37) with IV TXA. Furthermore, neither group required transfusions, nor were any thromboembolic complications noted for up to 6 months post-operation. Conclusion: Our study supports the use of TXA in TKA, as it effectively reduces perioperative blood loss, decreases the need for blood transfusions, and does not increase the risk of TE.

Gender Differences in Pain, Function, and Quality of Life Five Years Following Primary Total Knee Arthroplasty

BackgroundMultiple authors have sought to determine what patient characteristics influence outcomes after total knee arthroplasty (TKA). The impact of gender on outcomes after TKA remains controversial. Previous studies had less than 5 years of follow-up after TKA. The aim of this evaluation was to determine what differences in pain, function, and quality of life (QoL) exist between female and male patients 5 years after primary TKA. MethodsA prospective, multicenter cohort of 11,602 unilateral primary TKA patients (7,284 females and 4,318 males) was prospectively evaluated. All patients were enrolled in the Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement. Demographic data, musculoskeletal and medical comorbid conditions, and patient-reported outcome measures, including the Knee Injury and Osteoarthritis Outcome (KOOS) and Short-Form (36-item) Health Survey mental component score (MCS) and physical component score (PCS) were collected preoperatively and at 5 years after TKA. Descriptive statistics were generated, and stratified by gender, and differences in pain, function, and QoL between female and male patients were evaluated. Multivariate regression models with a 95% confidence interval (CI) were used to assess the role of patient gender as a predictive factor for KOOS pain and function in daily living (ADL) scores reported 5 years after primary TKA, while adjusting for other variables. ResultsPrior to surgery, female patients reported worse pain (KOOS pain 46 versus 52), function (KOOS ADL 53 versus 59), and QoL (KOOS QoL 26 versus 29) than male patients. The differences in preoperative scores ranged from 2.70 (KOOS QoL) to 6.12 (KOOS ADL). At 5 years after TKA, female patients reported slightly worse pain (87 versus 89), function (85 versus 87), and QoL (74 versus 75) when compared to male patients. The differences in the mean 5-year postoperative KOOS scores (range, 0.99 to 2.73), although statistically significant (P < .001), were clinically negligible. Female patients achieved greater improvement in pain (41 versus 37), function (32 versus 29), and QoL (48 versus 46) scores in comparison to male patients. Female patients also reported lower preoperative PCS global function (33 versus 35) scores, 5-year postoperative PCS scores (45 versus 46), and MCS global mental function scores (52 versus 54). Similarly, the differences in the 5-year postoperative Short-Form (36-item) Health Survey MCS and PCS scores were clinically negligible. Multivariate regression analysis showed that female gender was not independently predictive for either pain (β = −1.08; 95% CI [−1.25 to 1.03] [P = .85]) or function (β = 0.64; 95% CI [−0.51 to 1.79] [P = .28]) 5 years after surgery. ConclusionsThere are no clinically significant gender differences in pain, function, or QoL 5 years after TKA. Female patients typically have worse symptoms prior to surgery, improve more than male patients, and end up with pain, function, and QoL scores clinically equal to male patients. These data can enhance the shared decision-making process between female patients and surgeons and assist in setting appropriate patient expectations prior to TKA.

Single-center experience with Knee+™ augmented reality navigation system in primary total knee arthroplasty.

Computer-assisted systems obtained an increased interest in orthopaedic surgery over the last years, as they enhance precision compared to conventional hardware. The expansion of computer assistance is evolving with the employment of augmented reality. Yet, the accuracy of augmented reality navigation systems has not been determined. To examine the accuracy of component alignment and restoration of the affected limb's mechanical axis in primary total knee arthroplasty (TKA), utilizing an augmented reality navigation system and to assess whether such systems are conspicuously fruitful for an accomplished knee surgeon. From May 2021 to December 2021, 30 patients, 25 women and five men, underwent a primary unilateral TKA. Revision cases were excluded. A preoperative radiographic procedure was performed to evaluate the limb's axial alignment. All patients were operated on by the same team, without a tourniquet, utilizing three distinct prostheses with the assistance of the Knee+™ augmented reality navigation system in every operation. Postoperatively, the same radiographic exam protocol was executed to evaluate the implants' position, orientation and coronal plane alignment. We recorded measurements in 3 stages regarding femoral varus and flexion, tibial varus and posterior slope. Firstly, the expected values from the Augmented Reality system were documented. Then we calculated the same values after each cut and finally, the same measurements were recorded radiologically after the operations. Concerning statistical analysis, Lin's concordance correlation coefficient was estimated, while Wilcoxon Signed Rank Test was performed when needed. A statistically significant difference was observed regarding mean expected values and radiographic measurements for femoral flexion measurements only (Z score = 2.67, P value = 0.01). Nonetheless, this difference was statistically significantly lower than 1 degree (Z score = -4.21, P value < 0.01). In terms of discrepancies in the calculations of expected values and controlled measurements, a statistically significant difference between tibial varus values was detected (Z score = -2.33, P value = 0.02), which was also statistically significantly lower than 1 degree (Z score = -4.99, P value < 0.01). The results indicate satisfactory postoperative coronal alignment without outliers across all three different implants utilized. Augmented reality navigation systems can bolster orthopaedic surgeons' accuracy in achieving precise axial alignment. However, further research is required to further evaluate their efficacy and potential.

Routine pretransfusion testing before primary total hip or knee arthroplasty are an expensive and wasteful routine. Systematic review and meta-analysis.

The excessive routine ordering of pretransfusion tests (blood typing, screening, and cross-matching) for surgical cases incurs significant unnecessary costs and places an undue burden on transfusion services. This study aims to systematically review the literature regarding the necessity of routine pretransfusion tests before total hip arthroplasty (THA) or total knee arthroplasty (TKA) and summarize their outcomes. A systematic review and meta-analysis were performed. The study's characteristics, the prevalence of over-ordering pretransfusion tests, transfusion rates, and potential cost savings to the healthcare system were analyzed. The study included 17,667 patients. Pooled results revealed a 96.3% over-ordering pretransfusion test rate (95% CI: 0.92-1.00; p < 0.001) among patients undergoing primary THA or TKA. The pooled prevalence of hospital transfusion rate was 3.6%. Notably, there were statistically significant differences in preoperative hemoglobin (Hb) levels between patients not requiring transfusion (Hb = 13.9g/dl; 95% CI 12.59-15.20; p < 0.001) and those needing transfusion (Hb = 11.9g/dl; 95% CI 10.69-13.01; p < 0.001) (p = 0.03). The per-patient total cost savings ranged from 28.63 to 191.27 dollars. Our study suggests that routine pre-transfusion testing for all patients undergoing primary THA or TKA may be unnecessary. We propose limiting pretransfusion test orders to patients with preoperative hemoglobin levels below 12g/dl in unilateral primary TKA or THA. This targeted approach can result in significant cost savings for healthcare systems and transfusion services by reducing the over-ordering of pretransfusion tests in these surgical procedures.

Shorter length of stay and significant cost savings with ambulatory surgery primary unilateral total knee arthroplasty in Asians using enhanced recovery protocols

IntroductionEnhanced recovery after surgery (ERAS) in total knee arthroplasty (TKA) has reduced the length of stay (LOS) and cost of TKA in the Western population. Asians had been identified to be at higher odds of non-home discharge following TKA due to cultural differences. The efficacy of ERAS in TKA for Asian patients is less known. We aimed to investigate the efficacy of ERAS in reducing the LOS, transition to ambulatory surgery, improving home discharges, and reducing cost in an Asian population following TKA. MethodsRetrospective analysis was performed on 634 TKA patients in 2017 (pre- ERAS) and 584 TKA patients who had undergone ERAS in 2022 in a tertiary hospital. ResultsPatients in 2022 (ERAS) were older (69 ± 7 vs. 68 ± 7 years old, p < 0.001) and had a higher proportion of patients with poorer function (p < 0.001). The LOS reduced from 5.4 days (95% CI:5.2–5.6) to 2.9 days (95% CI:2.7–3.2) (p < 0.001) with about 49 % of patients transitioning to ambulatory surgery and having a LOS of 1.4 days (95 %CI:1.3–1.5). The proportion of patients being discharged home in 2022 (78.9 %) was higher compared to 2017 (62.2 %) (p < 0.001). This saved the hospital 1817.4 inpatient ward bed days, which translated to S$2,124,540.60 of cost saving in a year, and up to S$2397.28 for the individual patient. ConclusionERAS after TKA was able to safely achieve LOS comparable to the western population and allowed transition to ambulatory knee replacement in the Asian population. Consequently, this led to higher proportion of home discharges and achieved significant cost saving and hospital bed days.

Strengthening Quality Measurement to Predict Success for Total Knee Arthroplasty: Results from a Nationally Representative Total Knee Arthroplasty Cohort.

When performed well on appropriate patients, total knee arthroplasty (TKA) can dramatically improve quality of life. Patient-reported outcome measures (PROMs) are increasingly used to measure outcome following TKA. Accurate prediction of improvement in PROMs after TKA potentially plays an important role in judging the surgical quality of the health-care institutions as well as informing preoperative shared decision-making. Starting in 2027, the U.S. Centers for Medicare & Medicaid Services (CMS) will begin mandating PROM reporting to assess the quality of TKAs. Using data from a national cohort of patients undergoing primary unilateral TKA, we developed an original model that closely followed a CMS-proposed measure to predict success, defined as achieving substantial clinical benefit, specifically at least a 20-point improvement on the Knee injury and Osteoarthritis Outcome Score, Joint Arthroplasty (KOOS, JR) at 1 year, and an enhanced model with just 1 additional predictor: the baseline KOOS, JR. We evaluated each model's performance using the area under the receiver operator characteristic curve (AUC) and the ratio of observed to expected (model-predicted) outcomes (O:E ratio). We studied 5,958 patients with a mean age of 67 years; 63% were women, 93% were White, and 87% were overweight or obese. Adding the baseline KOOS, JR improved the AUC from 0.58 to 0.73. Ninety-four percent of those in the top decile of predicted probability of success under the enhanced model achieved success, compared with 34% in its bottom decile. Analogous numbers for the original model were less discriminating: 77% compared with 57%. Only the enhanced model predicted success accurately across the spectrum of baseline scores. The findings were virtually identical when we replicated these analyses on only patients ≥65 years of age. Adding a baseline knee-specific PROM score to a quality measurement model in a nationally representative cohort dramatically improved its predictive power, eliminating ceiling and floor effects and mispredictions for readily identifiable patient subgroups. The enhanced model neither favors nor discourages care for those with greater knee dysfunction and requires no new data collection. Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.