Unilateral Total Knee Replacement Research Articles

Comparative study of total knee replacement Vs non surgical treatment regarding management of knee osteoarthritis

Osteoarthritis (OA) is a type of joint disease that results from breakdown of joint cartilage and underlying bone. The most common symptoms are joint pain and stiffness. Osteoarthritis (OA) is a common disease of aged population and one of the leading causes of disability. Incidence of knee OA is rising by increasing average age of general population. Age, weight, trauma to joint due to repetiting movements in particular squatting and kneeling are common risk factors of knee OA. Several factors including cytokines, leptin, and mechanical forces are pathogenic factors of knee OA. Treatment options for osteoarthritis typically depend on the severity of the condition and the particular joints involved. They most often include medication Physical activity, stretching, and weight management, physical and occupational therapy, with or without assistive devices and surgery. The most common surgeries to treat knee arthritis are total knee replacement (total knee arthroplasty), partial knee replacement (unicompartmental knee arthroplasty), knee osteotomy (tibial osteotomy or femoral osteotomy), knee arthroscopy and cartilage repair and restoration. In this randomized, controlled trial, we enrolled 90 patients with moderate-to severe knee osteoarthritis who were eligible for unilateral total knee replacement. Patients were randomly assigned to undergo total knee replacement followed by 10 weeks of nonsurgical treatment (total-knee-replacement group) or to receive only the 10 weeks of nonsurgical treatment (nonsurgical-treatment group), which was delivered by physiotherapists and dietitians and consisted of exercise, education, dietary advice, use of insoles, and pain medication. The primary outcome was the change from baseline to 10 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, activities of daily living, and quality of life (KOOS4); scores range from 0 (worst) to 100 (best). A total of 80 patients completed the 10-month follow-up assessment. In the nonsurgical-treatment group, 11 patients underwent total knee replacement before the 10-month follow-up; in the total-knee-replacement group, 1 patient received only nonsurgical treatment. In the intention-to-treat analysis, the total-kneereplacement group had greater improvement in the KOOS4 score than did the nonsurgical- treatment group. The total-knee-replacement group had a higher number of serious adverse events than did the nonsurgical-treatment group. In patients with knee osteoarthritis who were eligible for unilateral total knee replacement, treatment with total knee replacement followed by nonsurgical treatment resulted in greater pain relief and functional improvement after 10 months than did nonsurgical treatment alone. However, total knee replacement was associated with a higher number of serious adverse events than was nonsurgical treatment, and most patients who were assigned to receive nonsurgical treatment alone did not undergo total knee replacement before the 10-month follow-up.

Prevalence and determinants of physical activity and sedentary behaviour before and up to 12 months after total knee replacement: a longitudinal cohort study

Objective: This study aims to evaluate the prevalence and determinants of inadequate physical activity and excessive sedentary behaviour before and after total knee replacement. Design, setting and subjects: Secondary analysis was performed on data from a cohort of 422 adults (45–74 years), drawn from 12 public or private hospitals, undergoing primary unilateral or bilateral total knee replacement surgery. Main measures: Questionnaires were used to determine the presence of inadequate physical activity and excessive sedentary behaviour before and 6 and 12 months after total knee replacement surgery. Knee pain, activity limitations, comorbidities, muscle strength, psychological well-being, fatigue, sleep and body mass index were measured/assessed as possible determinants of physical activity or sedentary behaviour. Results: Before surgery, 77% (n = 326) of the cohort participated in inadequate physical activity according to World Health Organization guidelines, and 60% (n = 253) engaged in excessive sedentary behaviour. Twelve months after surgery, 53% (n = 185) of the cohort engaged in inadequate physical activity and 45% (n = 157) in excessive sedentary behaviour. Inadequate physical activity before surgery (P = 0.02), obesity (P = 0.07) and comorbidity score >6 (P = 0.04) predicted inadequate physical activity 12 months after surgery. Excessive sedentary behaviour and activity limitations before surgery predicted excessive sedentary behaviour 12 months after surgery. Conclusion: Although there were improvements after total knee replacement, 12 months after surgery about half the cohort did not meet World Health Organization recommendations for activity. Pre-surgery assessment of physical activity, activity limitations, sedentary behaviour and body mass index is essential to identify patients at risk for long-term inactivity.

Surgical site infection surveillance following total knee arthroplasty: Tertiary care hospital experience.

IntroductionSurgical Site Infection (SSI) after knee arthroplasty is a major cause of morbidity and mortality that increases the hospital stay, financial burden and mental anguish of the patient. Infection Control Unit at Aga Khan University Hospital (AKUH) incorporated total knee arthroplasty in its surgical care surveillance program and started collecting data in June 2012. The purpose of this study is to review Surgical Site Infection (SSI) rates in patients undergoing primary total knee replacement (TKR) surgery.Patients and methodologyAll patients from June 2012 to December 2013 undergoing knee arthroplasty at our hospital were included. Data was acquired from the hospital SSI database for knee arthroplasty surgery. Data was collected by SSI nurses for inpatients a well as post-discharge monitoring in clinics till 90 days post-op follow-up. The work has been reported in line with the PROCESS criteria.ResultsDuring this time period a total of 164 patients had primary TKR at AKUH. Out of these, 85 patients (52%) had bilateral TKR while 79 (48%) had unilateral TKR. The overall SSI was in 2 patients (1.2%).ConclusionIdentifying SSIs is multidimensional. Since our 2 infected cases after TKR occurred after discharge, this highlights the importance of post-discharge surveillance and not limiting the surveillance for inpatients only. Furthermore, the SSI program may be effective in controlling postoperative wound infections.

A Physical Therapist–Administered Physical Activity Intervention After Total Knee Replacement: Protocol for a Randomized Controlled Trial

The definitive treatment for knee osteoarthritis is a total knee replacement, which results in a clinically meaningful improvement in pain and physical function. However, evidence suggests that physical activity (PA) remains unchanged after total knee replacement (TKR). The objective of this study is to investigate the efficacy, fidelity, and safety of a physical therapist-administered PA intervention for people after TKR. This study will be a randomized controlled trial. The setting is an outpatient physical therapy clinic. The participants are 125 individuals who are over the age of 45 and are seeking outpatient physical therapy following a unilateral TKR. In addition to standardized physical therapy after TKR, the intervention group will receive, during physical therapy, a weekly PA intervention that includes a wearable activity tracking device, individualized step goals, and face-to-face feedback provided by a physical therapist. The control group will receive standardized physical therapy alone after TKR. The efficacy of the intervention will be measured as minutes per week spent in moderate to vigorous PA at enrollment, at discharge, and at 6 months and 12 months after discharge from physical therapy. The fidelity and safety of the intervention will be assessed throughout the study. Participants will not be masked, PA data will be collected after randomization, and the trial will be conducted at a single site. The goal of this randomized controlled trial is to increase PA after TKR. A protocol for investigating the efficacy, fidelity, and safety of a physical therapist-administered PA intervention for people after TKR is presented. The findings will be used to support a large multisite clinical trial to test the effectiveness, implementation, and cost of this intervention.

No difference in the functional improvements between unilateral and bilateral total knee replacements

BackgroundDifferences between staged bilateral total knee replacement (TKR) and simultaneous bilateral TKR have been investigated, but few studies have investigated differences in the functional improvements resulting from these methods. Therefore, this study investigates the different functional improvements between staged bilateral total knee TKR and simultaneous bilateral TKR.MethodsAmong 144 potential bilateral TKR patients who were included in this study, 93 (64.6%) patients selected unilateral TKR and 51 (35.4%) selected bilateral TKR. Functional improvements were assessed using the Western Ontario and McMaster University osteoarthritis index (WOMAC) and the Medical Outcomes Trust Short Form-36 (SF-36), and patients were interviewed pre-operatively and after 6 months. A generalized equation was used to test for differences in functional improvements.ResultsAfter TKR, pain, stiffness, function and total WOMAC scores were significantly reduced in both groups, with mean changes from − 26.6 to − 41.4 and from − 27.5 to − 42.2.The mean health change of SF-36 scores, physical component and mental component scores changed to 45.2 ± 18.2, 74.0 ± 15.4 and 77.0 ± 9.6, respectively, in Group 1 and 47.1 ± 17.1, 74.0 ± 15.2 and 75.5 ± 12.1, respectively, in Group 2.Unilateral and simultaneous bilateral TKR produce similar functional improvements, although current work status may be a novel impact factor.ConclusionNo differences in functional improvements were identified between patients who selected unilateral versus bilateral TKR, indicating no recommendation for one procedure over the other.

Sequential two stage release for genu valgum correction in total knee replacement

<p class="abstract"><strong>Background:</strong> <span lang="EN-IN">Valgus deformity presents a major challenge in total knee replacement, especially in moderate or severe cases. Many surgical techniques have been described to balance<sup> </sup>the soft tissues in correction of a severe valgus deformity<sup> </sup>during total knee replacement. The structures most commonlyreleased in a valgus knee include the posterolateralaspect of the capsule, iliotibial band (IT band), the lateral collateral ligament (LCL), the popliteustendon, and the lateral head of the gastrocnemius muscle.</span></p><p class="abstract"><strong>Methods:</strong> <span lang="EN-IN">thirty two patients undergoing unilateral total knee replacement were followed for the evaluation of study. There were 22 female (68%) and 10 males (32%) with an age of 62.7±6.9 years (range 50-75) with valgus deformity of 18.59˚±8.32˚ (range 10-40˚). Preoperative diagnosis was rheumatoid arthritis in 23 patients (72%) and osteoarthritis in 9 patients (28%). Posterior stabilizing cemented implants were used</span>.<strong></strong></p><p class="abstract"><strong>Results:</strong> <span lang="EN-IN">Based on total knee score we achieved 21 (63.64%) excellent, 10 (31.82%) good and 1 (4%) fair results. With the total functional score we had 16 (50%) excellent, 15 (45.45%) good and 1 (4%) fair results. In patients with only step1 release (17 patients) we achieved 84% (15 pts) excellent, 8% (1 pt) good, 8% (1 pt) fair with knee score; and 67% (11pts) excellent, 33% (6pts) good with functional score. In step 2 release group (15 pt) we achieved 10% (1 pt) excellent, 90% (14 pts) good with knee score; and 10% (1pt) excellent, 80% (13 pts) good and 10% (1 pt) fair with functional score. </span></p><p class="abstract"><strong>Conclusions:</strong> <span lang="EN-IN">Good to excellent results can be achieved with two step sequential lateral release of posterolateral capsule and IT band pie-crusting which has direct correlation with severity of valgus deformity. The safety, simplicity, and high success rate of the two step sequential lateral release of posterolateral capsule and pie-crusting of IT band justify its routine use to correct every valgus deformity in total knee replacement.</span></p>

Reported balance confidence and movement reinvestment of younger knee replacement patients are more like younger healthy individuals, than older patients

This study focused on differences between the rapidly growing younger (<65 years old) and older (>65 years old) total knee replacement (TKR) patients for measures of balance confidence, movement reinvestment, and functional mobility. Fifty-nine participants, including twenty-nine primary unilateral TKR patients (six months post-TKR) formed the four experimental groups: 1) Younger TKR Patient (YP), 2) Younger Control (YC), 3) Older TKR Patient (OP), and 4) Older Control (OC). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Oxford Knee Score (OKS), Activities-specific Balance Confidence scale (ABC), the Movement-Specific Reinvestment Scale (MSRS), and the Timed Up and Go (TUG) test were measured. The YP group reported a significantly lower WOMAC score (p < 0.001), and higher perceived knee joint function (p = 0.001), compared to the OP group. The YP group also reported significantly higher balance confidence (p < 0.001) and less movement reinvestment (p = 0.001) than the OP group. TUG durations revealed that the YP group had significantly higher functional mobility compared to the OP group (p = 0.001). The YP group did not differ from the YC group across any of these measures (p > 0.05). These results identify a clear distinction between younger and older TKR patients for fall risk and TKR outcome, which argues that age should be a factor clinicians take into account when addressing the management and care of individuals recovering from TKR.

Analysis of inpatient costs in patients with knee osteoarthritis treated by implantation of total condylar knee endoprosthesis

Background/Aim. Total knee replacement is an elective and high cost surgical procedure which is performed more frequently as a result of increasing prevalence of knee osteoarthritis. The aim of this study was to provide insight into the value and structure of inpatient costs associated with total knee replacement in Serbia. Methods. This study was conducted as an in-depth, bottom-up, retrospective, case series analysis of services consumption patterns and costs associated with inpatient treatment of patients with knee osteoarthritis by implantation of primary total condylar knee endoprosthesis from perspective of the national Republic Health Insurance Fund. We obtained data on 97 patients treated with primary unilateral or bilateral total knee replacement in 2014 at the Clinic for Orthopaedic Surgery and Traumatology of the Military Medical Academy in Belgrade, a tertiary health care university hospital. Results. Mean age of entire study sample was 67.89 years. Majority of patients (60 patients; 61.9%) had unilateral implantation of total condylar knee endoprosthesis. Bilateral implantation was performed in 37 (38.1%) patients. Mean total inpatient cost per patient for both unilateral and bilateral implantation of total condylar knee endoprosthesis was EUR 2,709.1, ranging from EUR 1,685.2 to EUR 5,356.6. Mean total inpatient cost per patient was EUR 2,093.8 for unilateral implantation and EUR 3,706.8 for bilateral implantation. Two major cost drivers were surgery specific material and surgery. Cost of implants was the highest single cost driver in all observed groups of patients. Conclusion. Our findings imply that inpatient costs associated with implantation of primary total condylar knee endoprosthesis are substantial. It seems that the most important cost drivers are surgery and surgery specific material, with implants being the highest single cost driver. Further research should be focused on analyzing factors that influence these costs in order to develop effective strategies which could contribute to substantial savings in the future.

Fat Embolism Syndrome in a Patient who Underwent Unilateral Total Knee Replacement

Fat Embolism Syndrome in a Patient who Underwent Unilateral Total Knee Replacement

The Effect of Total Knee Arthroplasty on Active Knee Extension During Treadmill Walking

Determination of whether patients who receive full extension following a TKA use this full range of motion when they commence pain-free walking post-operatively. Fixed flexion contracture of the knee due to osteoarthritis is common in patients requiring a total knee arthroplasty (TKA). This is detrimental to overall knee function and increases energy expenditure during walking. Individuals may also consciously limit extension during walking to minimize pain or avoid joint instability. TKA is a well-established procedure for restoring extension, however there is a suspicion that despite receiving a knee capable of achieving full extension, patients do not utilise this capability post-operatively. The purpose of this study was to determine whether patients who receive full extension following a TKA use this full range of motion when they commence pain-free walking post-operatively. Gait analysis of patients undergoing unilateral TKR was conducted prior to surgery and repeated when they commenced pain-free locomotion. A high-speed optoelectronic camera system (200Hz, Vicon Bonita/Nexus, UK) was used to record maximum knee extension of the operated limb during standing and while supine (passive knee extension), step-descent onto the injured limb from a 20cm high step, as well as treadmill walking at both a self-selected comfortable speed and 130% (“fast”) of that speed for one minute each. Student t-tests were used to compare differences between pre-operative and post-operative values for the cohort aggregated and for each patient (single-case). A cohort of 24 patients (15 females; 70.8±6.5yrs; 168.8±8.9cm; 84±13.2kg) was assessed before, during and 4.7±0.5 months after surgery. On average, patients displayed fixed flexion preoperatively during the passive supine measurement (14.7°, 12.8-19.3), did not fully extend during the step-descent (14.9°, 17.3-13.9) or during treadmill walking at both self-selected comfortable (17.6°, 20.8-13.8) and fast (17.1°, 20.2-13.9) speeds. Postoperatively, fixed flexion during the supine measurement improved significantly (P<0.01) to 3.7° (1.6 – 5), however 33.3% of knees exhibited >5° flexion and 58.3% exhibited >3°. The use of knee extension increased significantly, on average, for standing, stepping and walking. Single case comparisons indicated that for the stepping task, all but 3 patients significantly improved the maximum extension value during the post-operative assessment (p < 0.05). For the comfortable and fast walking tasks, all patients achieved a significantly (p < 0.05) greater maximum extension angle. However, the majority of patients (75-92%) used significantly (P<0.05) less extension during locomotion compared to the passive supine measurement, and minimum knee flexion during walking remained significantly higher than for healthy geriatric populations. TKR patients utilise improved extension during passive measurement and locomotion following surgery. The amount of improvement did not differ across the functional tasks. However, patients did not utilise the full amount of extension restored intra-operatively. These results highlight the importance of focused rehabilitation during the post-operative period aimed at optimising extension during gait, in order to achieve the best functional outcome.

Bilateral Sequential Total Knee Replacement Versus Unilateral Total Knee Replacement in a High Volume Hospital: 在大手術量醫院中雙側順序全膝關節置換術與單側全膝關節置換術的比較

Background/purposeBilateral simultaneous or sequential total knee replacement (TKR) is performed on a portion of patients but the benefits and risks remain controversial. MethodsA total of 89 sequential bilateral TKR (BTKR) patients were compared with 89 unilateral TKR (UTKR) patients in our total joint replacement centre from October 2011 to October 2014. The baseline parameters were matched and postoperative results were compared. ResultsThe BTKR group had a shorter length of stay per knee (4.8 days vs. 6.5 days) but with a higher total drain output, higher haemoglobin drop, higher transfusion rate, and more postoperative acute retention of urine. Both groups had similar major complication rates and no 90 days mortality. ConclusionBTKR is a safe surgery in selected patients performed in a high volume hospital with fast-track programme.

Comparison of clinical results for patients undergoing unilateral total knee replacement with or without tranexamic acid

Comparison of clinical results for patients undergoing unilateral total knee replacement with or without tranexamic acid

EFFECTS OF EARLY REHABILITATION PROTOCOL POST HIGH FLEX CRUCIATE RETAINING TOTAL KNEE REPLACEMENT ON RANGE OF MOTION, PAIN AND FUNCTION: A PROSPECTIVE STUDY

Purpose: The purpose of the study was to find the effects of early rehabilitation on high flex cruciate retaining total knee replacement (TKR) on pain and function. Methods: We designed a prospective pre-post trial and evaluated 34 participants who underwent unilateral TKR following end stage knee osteoarthritis. Outcome measure of numeric pain rating scale (NPRS), knee ROM, quadriceps strength and functional measure of timed up and go test (TUG) and six-minute walk test (SMWT) was assessed before and three months post surgery by a blinded observer. Results: The knee flexion ROM showed significant improvement of 25.1∘[Formula: see text]±[Formula: see text]11.2∘at 3-months. The NPRS, TUG and SMWT showed significant change of 6.47[Formula: see text]±[Formula: see text]0.92, 21.7[Formula: see text]±[Formula: see text]2.6, 157.7[Formula: see text]±[Formula: see text]31 from baseline to 1.3[Formula: see text]±[Formula: see text]0.8, 17.5[Formula: see text]±[Formula: see text]1.6, 263[Formula: see text]±[Formula: see text]37.9 at 3 months respectively following TKR (p = 0.001). Conclusion: Early rehabilitation showed improvement in knee ROM, pain reduction, and accelerated recovery in performing TUG and SMWT.

Effect of intravenous tranexamic acid on blood loss and blood transfusion in total knee replacement: a prospective, randomized study in Indian population

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Tranexamic acid (TXA) is antifibrinolytic drug which has the property to reduce intraoperative and postoperative bleeding. There are several studies supporting the use of tranexamic acid in total knee replacements (TKR) and few in total hip replacements. Our study was intended to establish the effects of tranexamic acid in minimizing the intra operative and post-operative blood loss in uncomplicated primary total knee replacement.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This was a prospective follow up study conducted in Rajarajeshwari Medical College and Hospital Bangalore, over a period of 14 months from June 2015 to August 2016. A total number of 60 patients who underwent unilateral primary total knee replacement were included for this study. They were randomly divided into 2 groups. Group I patients infused (intravenous) with 20 mg/kg TXA before incision and 3 hours after surgery whereas no TXA was administered in Group II. Total blood loss and transfusion rate were used as outcome. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mean amounts of blood loss were 578 ml in Group 1 and 946 ml in Group 2. There was a decrease in blood loss in TXA groups (p&amp;lt;0.001). Transfusion was required in 6 patients of Group I and 17 patients of Group II (p&amp;lt;0.001). No thromboembolic problem was seen in any patients.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Since TXA decrease perioperative blood loss and lessen the need for blood transfusion significantly, without increasing thromboembolic events in TKR. We suggest using intravenous (IV) TXA in TKR. &lt;/p&gt;

Comparison of intravenous and intra-articular tranexamic acid in reducing blood loss in primary total knee replacement.

This study aims to compare the efficacy and safety of intra-articular tranexamic acid (TA) versus intravenous (IV) TA in the reduction of perioperative blood loss and the degree of early postoperative complications associated with primary unilateral cemented total knee replacement. This prospective randomized study included 90 patients (36 males, 54 females; mean age 68.7 years; range 47 to 82 years) with knee osteoarthritis undergoing a unilateral cemented total knee replacement. Patients were randomized into three groups: group 1 received TA intravenously (dose 10 mg/kg) 20 minutes preoperatively and three hours after first dose, group 2 received TA (dose 3 g) locally (intra-articular) into surgical site, and group 3 did not receive TA. We measured perioperative blood loss, volume of drained blood in 24 hours postoperatively, overall blood loss, decrease in hemoglobin and hematocrit levels, and amount of blood transfusion. There were no differences between the groups in terms of patient preoperative demographics. Local or IV administration of TA significantly reduced the number of blood transfusions and blood losses in drainage. Intravenous application of TA was associated with statistically significantly higher hemoglobin and hematocrit levels and lower overall postoperative blood losses. No serious complications were observed in any of the groups. Intra-articular TA was equally effective as IV regimen in reducing the number of blood transfusions. However, IV administration of TA was associated with overall lower blood loss. Our results showed that IV administration of TA during total knee replacement is superior compared to intra-articular administration of TA.

Gait symmetry in walking and running after unilateral total knee replacement: Is there a relationship between walking and running symmetry?

The purpose of this study was to quantify the initial stability of a highly porous titanium cup using an acetabular bone defect model.The maximum torque of a highly porous titanium cup, with a pore size of 640 μm and porosity of 60%, was measured using rotational and lever-out torque testing and compared to that of a titanium-sprayed cup. The bone models were prepared using a polyurethane foam block and had three levels of bone coverage: 100, 70, and 50%.The highly porous titanium cup demonstrated significantly higher maximum torque than the titanium-sprayed cups in the three levels of bone defects. On rotational torque testing, it was found to be 1.5, 1.3, and 1.3 times stronger than the titanium-sprayed cups with 100, 70 and 50% bone coverage, respectively. Furthermore, it was found to be 2.2, 2.3, and 1.5 times stronger on lever-out testing than the titanium-sprayed cup. No breakage in the porous layers was noted during the testing.This study provides additional evidence of the initial stability of highly porous titanium cup, even in the presence of acetabular bone defects.

A prospective randomized pilot study of steroid modulation of cytokine (Interleukin 6) release in unilateral total knee replacement surgeries

Several studies evaluating the patients undergoing joint replacement have found elevation in the levels of cytokine interleukin-6(IL-6). High level of IL-6 after the major surgeries have been linked to postoperative fever, confusion, pain, acute respiratory distress syndrome, fat embolism syndrome. Pre and post-operative administration of low dose steroid (Inj. Hydrocortisone 100mg) in patients undergoing TKR has shown to reduce the inerleukin-6 level and its complications. The purpose of this study was to observe the effect of intravenous hydrocortisone on cytokine Interleukin-6 (IL-6) as primary outcome and also to observe presence of Fever, Blood sugar level (BSL), Pain score (using Visual analogue scale), Range of motion (ROM) and Spo2 (Saturation of oxygen) as a secondary outcome in the patients undergoing unilateral total knee arthroplasty. In our study 30 Patients were randomized into 2 groups. The study group received first dose of injection hydrocortisone 100mg I.V at the start of surgery followed by two more doses given eight hours apart while the control group received 100 ml of NS at similar intervals. From this study, we conclude that a low dose of hydrocortisone given for a short period of over 24 hours perioperatively to the patients having unilateral total knee arthroplasty are associated with decreased level of inflammatory marker, the cytokine Interleukin-6 (IL-6). The benefits included decrease pain scores, better saturation of oxygen (Spo2), lower prevalence of fever and better range of motion.

Comparison of epidural Ropivacaine 0.75% and Ropivacaine 0.75% Plus Buprenorphine (0.5 ml) for total knee replacement surgery

Aim and Objectives: To assess the comparison between ropivacaine and combination of ropivacaine with buprenorphine in terms of onset and duration of analgesia, cardiorespiratory effects, side effects and post-operative analgesia. Methods: Total 60 adult patients of either sex, ASA grade I - II, schedule for total knee replacement surgery were enrolled in the study and randomized into two groups. Group R: received 14.5ml of 0.75% plain Ropivacaine + 0.5ml Normal saline (NS) making volume 15ml. Group RB: received 14.5ml of 0.75% plain Ropivacaine + Buprenorphine 150 mics (0.5ml) making volume 15ml. Onset of sensory-motor block, hemodynamic variables (HR, SBP, DPB, MAP, RR), duration of analgesia were recorded. Results: The onset of sensory blockade was earlier in group R as compared to in group RB. The motor onset time was similar in both the groups. The mean hemodynamic parameters were comparable in both the groups. Duration of analgesia was prolonged in group RB as compared to group R. Group RB had more incidences of post-op vomiting (36.67%) and pruritus (3.3%) as compared to group R. Conclusion: The addition of buprenorphine to epidural ropivacaine is a well tolerated, effective method for epidural anesthesia in patients undergoing unilateral total knee replacement surgery.

C-reactive protein course during the first 5 days after total knee arthroplasty cannot predict early prosthetic joint infection.

Periprosthetic joint infection (PJI) is one of the most devastating major complications after total knee arthroplasty (TKA). The laboratory value C-reactive protein (CRP) is the inflammatory biomarker most suitable for detecting a potential postoperative (p.o.) early infection in orthopaedic surgery. However, on the basis of multiple receiver operating characteristic (ROC) analyses, CRP only has limited sensitivity and specificity. The objective of the present study was to test the hypothesis that, besides the absolute preoperative CRP value, also the absolute postoperative CRP value and its course over the first 5 days after TKA are valid indicators of periprosthetic early infection. A total of 1068 subjects who had been treated with a unilateral primary cemented total knee replacement due to primary osteoarthritis of the knee were included in the study. Retrospectively, for all patients, the preoperative CRP value, the p.o. CRP course and a history of the medical course, including any superficial surgical site infection (SSI) or deep PJI of the knee joint operated on, were recorded; further, any follow-up operations (septic revision) were documented. Using receiver operating characteristic (ROC) analysis, an optimum preoperative CRP cutoff value for the positive prediction of a PJI was determined. 34 of 1068 patients developed an SSI or a PJI that had to be revised. After TKA implantation, the CRP value increased significantly and achieved its maximum between the second and third p.o. day. At no p.o. day was there a difference in CRP between patients who developed an SSI or a deep PJI and patients with a normal complication-free p.o. In contrast, the preoperative CRP value proved to be a reliable predictor for septic revision due to an SSI or a PJI: the ROC analysis showed the optimum preoperative CRP cutoff value for a positive prediction of PJI to be 5mg/L. The most important finding of the present study is that neither the absolute p.o. CRP value nor its course in the first 5days after TKA is suitable for detecting an early infection. In contrast, an increased preoperative CRP value proved to be a valid predictor for septic revision due to an SSI or a PJI after TKA.

Multifactorial analysis of patient dissatisfaction after TKR – the influence of psychological factors

Objectives:The published rates of dissatisfaction following total knee replacement (TKR) range between 11-18%, with residual symptoms and psychological distress being important features. The aims of this study were to identify the prevalence and causes of dissatisfaction in a cohort of private practice patients, and to describe a post-operative management program which may improve satisfaction with their replaced knee in these patients.Methods:A cohort of 375 patients with unilateral TKR was evaluated to identify patients who were dissatisfied with TKR. Dissatisfied and satisfied patients were matched in terms of age, gender, follow-up duration and BMI. Psychological evaluation was performed using the pain catastrophizing scale (PCS), Depression, Anxiety and Stress Scale (DASS) and the Multidimensional Health Locus of Control (MHLC) scale. The pre and post-operative Oxford knee scores (OKS) and range of motion (ROM), preoperative grade of osteoarthritis, and prevalence of comorbidities were also compared between groups. Patients indicating dissatisfaction with their TKR were then followed up by phone on a second occasion 12months later. Those that indicated enduring dissatisfaction were invited to participate in a chronic pain program utilising cognitive behavioural therapy, desensitisation and coping strategies. Patients referred to the program were screened by the therapists for inclusion and enrolled into a flexible course of therapy. Pre- and post- intervention questionnaires will be used to determine the effect of the program on satisfaction rates (5-point Likert scale) and psychological responses to pain.Results:The final cohort consisted of 301 patients (response rate 80%), with 24 patients (6.5%) dissatisfied with the result of TKR. Persistent pain was the most common reason for dissatisfaction (n=10). Dissatisfied patients reported a significantly (P = 0.03) higher mean PCS score (mean±SD, 11.3±10.3), compared to satisfied patients (5.4±6.3) and a significantly (P = 0.02) higher depression component of the DASS (3.5±3.3 vs 1.4±1.6). In addition, dissatisfied patients returned a significantly (P = 0.02) lower internal locus of control (16.6±8.2 vs 21.3±8.2). The dissatisfied group also exhibited a reduced improvement in the OKS and ROM, as well as a lower preoperative grade of osteoarthritis compared to satisfied patients. Preliminary analysis revealed that five patients (21%) became satisfied with their knee despite no intervention occurring between measurements. Of the remaining patients, five patients (21%) did not think their ongoing issues were severe enough to warrant further intervention, and nine patients (38%) were referred directly to the program. It is expected that these results will shed new light on the potential management options for these patients that identify as dissatisfied after a primary unilateral TKR.Conclusion:Dissatisfied patients exhibit higher scores for catastrophisation and depression, with lower self confidence in managing their knee symptoms. In addition, they have lesser improvements in the OKS and ROM. Thus, both physical as well as psychological factors contribute to dissatisfaction. Identification of these factors can help in planning focused interventions to address dissatisfaction. This is the longest follow-up of such a cohort; our results so far indicate that 21% of such patients can improve spontaneously with time which challenges some conventional beliefs. The results of the 38% of patients who remain dissatisfied and will undergo the program will determine whether such an intervention will be worthwhile in this difficult clinical situation.