Abstract Liposomal bupivacaine periarticular injection (PAI) offers sustained bupivacaine release after TKA, but few prospective independent studies exist. In this prospective, blinded study, ...liposomal bupivacaine was randomized against bupivacaine and incorporated into a comprehensive multimodal pain management protocol. 111 primary TKAs were randomized to receive PAI: 58 patients received 266 mg (20 cc) liposomal bupivacaine mixed with 75 mg (30 cc) 0.25% bupivacaine, and 53 patients received 150 mg (60 cc) 0.25% bupivacaine. Visual analog pain scores and narcotic use were determined. No pain score differences occurred between study and control patients: Day 1: 4.5/4.6 ( P = 0.73); Day 2: 4.4/4.8 ( P = 0.27); or Day 3: 3.5/3.7 ( P = 0.58). Narcotic use was similar during hospitalization, 51.8/54.2 ( P = 0.34). The study medication costs $285, and the control medication costs $2.80. This finding does not justify the routine use of liposomal bupivacaine.
Abstract Background Despite pain resolution in most patients after total knee arthroplasty (TKA), poor function persists in approximately 20% of patients and frequently is associated with patient ...dissatisfaction. Lumbar spine problems are a leading cause of functional disability. This study sought to determine the association between lower knee function scores and history of spine disability. Methods Prospective demographic, health, and knee-specific data were collected for 1156 consecutive TKAs from July 2010 to July 2012. A spine questionnaire and Oswestry Disability Index (ODI) score were obtained from 691 knees. Results Of 691 patients, 371 (54%) with TKA had daily back pain or back pain that limited activity. Oxford Knee Score was significantly worse in patients with vs without back problems preoperatively (36.9/34.8; P = .0006) and postoperatively (20.2/17.0; P < .0001), but not for improvement (16.7/17.8; P = .10). Knee Society (KS) pain scores were similar regardless of spine history. KS function scores were lower in patients with vs without back problems preoperatively (42.3/47.0; P = .0005), postoperatively (69.0/79.8; P < .0001), and for improvement (25.8/32.9; P < .0001). Lower KS function was associated with female gender, age, health, preoperative function, and ODI. ODI was associated with Oxford Knee Score (R = 0.57) and KS function score (R = 0.54). Conclusion Knee function scores were significantly worse in patients with a history of back problems and directly associated with ODI score. KS function scores indicated that TKA patients with back problems had worse function before and after TKA with less improvement. Poor TKA outcomes and dissatisfaction may reflect poor knee function, spine disability, or both. Awareness of coexisting spine disability should guide patient expectations and evaluation of TKA outcomes.
To determine the cost-effectiveness of knotted (KT) versus knotless (KL) methods for rotator cuff surgical repair and to assess differences in patients’ outcomes.
We retrospectively identified all ...patients who underwent arthroscopic rotator cuff repair at 1 institution by 1 surgeon over 2 6-month periods of time (KT technique from August 1, 2013, through January 31, 2014; and KL technique from December 1, 2014, through May 31, 2015) to calculate the direct and indirect costs associated with arthroscopic KT or KL suture bridge rotator cuff repair. Patient demographics, number of anchors used, tendons repaired, procedure time, operative time, and clinical results were also evaluated. We used univariate generalized linear models with a Gaussian distribution for assessment scores and total and implant cost data.
We identified 87 patients for inclusion during the 2 time frames (35 KT, 54 KL). After excluding patients for tear size < 4 cm2 (n = 42), ≤ 3 anchors (n = 5), revision surgery (n = 1), and those in whom additional procedures were performed (n = 2), 37 eligible subjects remained (nKT = 15, nKL = 22). Median implant costs were statistically significantly higher in the KL group than in the KT group (MKL = $2,127, MKT = $1,520, β = 413.7, 95% CI: 242.8, 584.6, P < .01), and more anchors were used in the KL group, with KT requiring a median of 4 anchors (IQR: 4, 5) and KL requiring a median of 5 anchors (IQR: 5, 5, P = .02). Procedure time was cut in half with KL repair (estimated 43.5 minutes) versus KT repair (80 minutes) (β = 0.5, 95% CI: 0.4, 0.6, P < .001). Operating room time also was reduced by approximately 40% (79.5 minutes for KL; 121 minutes for KT β = 0.6, CI: 0.6, 0.7, P < .001). Once operating room costs were considered, median costs were found to be significantly lower in the KL group (MKL = $3788.40, MKT = $4262.90, β = –492.1, 95% CI: –840.0, –144.1, P < .01). No statistically significant differences were found between groups in mean preoperative, postoperative or postpreoperative differences in the visual analog scale, Simple Shoulder Test, American Shoulder and Elbow Surgeons, or University of California at Los Angeles scores (P > 0.05 for all).
Despite using more anchors and incurring higher implant costs, the KL technique for rotator cuff repair required less surgical procedure time and cost less overall than the KT technique and resulted in equivalent clinical results.
Level IV Economic and Decision Analyses.
Abstract Fifty patients underwent isokinetic muscle strength testing before surgery and at 6 weeks, 3 months, 6 months, and 1 year after unilateral total knee arthroplasty using the minisubvastus ...surgical technique. Quadriceps muscle strength returned to preoperative levels by 3 months postoperatively and was 17% stronger at 6 months and 30% stronger at 1 year than preoperative levels ( P < .05). At 1 year, the quadriceps strength of the involved knee was equivalent to that of the uninvolved knee ( P = .81). When the entire study population was subdivided by age, weight, sex, and the presence of arthritis in the uninvolved knee, each subgroup still had equivalent quadriceps strength between the involved and uninvolved knees. This prospective study demonstrated that the minisubvastus total knee arthroplasty technique led to a more rapid and more complete recovery of muscle strength than has been previously demonstrated after total knee arthroplasty with a medial parapatellar arthrotomy.
Use of anti-inflammatory medications (NSAIDs) is an important component of multimodal pain control after orthopedic procedures to avoid opioid overutilization and abuse. However, the deleterious ...effects of NSAIDs on tendon healing are of particular concern in rotator cuff repair (RCR). The purpose of this study was to evaluate the effect of celecoxib or placebo on healing rates after RCR when administered in the perioperative and immediate postoperative period using MRI evaluation at one year postoperatively. A secondary aim was to determine whether clinical differences existed between patients with intact or non-intact repairs.
Patients aged ≤65 years with partial- or full-thickness rotator cuff tear (<25x25 mm) were randomized to receive celecoxib 400 mg or placebo 1 hour before the procedure and 200mg bid for 3 weeks postoperatively. All patients were treated as clinically indicated at the time of surgery and followed standard postoperative protocol. Repair integrity was evaluated with MRI using the Sugaya classification for repair integrity. Data were analyzed using multivariable logistic regression by intent to treat.
Seventy-nine patients were enrolled; 21 were lost to follow-up, 6 did not have cuff repair, 5 were revised, and 2 declined follow-up, leaving 45 patients with one-year follow-up. Five of these patients did not complete MRI, leaving 40 patients for review. Eighteen of 20 patients (90%) who received celecoxib completed all doses of study medication as did 15 of 20 patients (75%) who received placebo. The patient groups were similar for demographics, clinical results, and healing rate. After adjusting for tear size, no statistically significant difference in healing rate was found between groups, with 10 of 20 celecoxib patients (50%) having intact repair at 1 year compared with 14 of 20 placebo patients (70%) (OR = 0.53, 95% CI: 0.14, 2.08, P = 0.35).
Half of the patients who received celecoxib had an intact repair compared with 70% intact repair for patients receiving placebo. Although not statistically significant in this small study, larger studies are needed to clarify this important clinical concern. The authors do not recommend use of celecoxib for postoperative pain control after RCR.
Mini-Subvastus Approach for Total Knee Arthroplasty Schroer, William C., MD; Diesfeld, Paul J., PA-C; Reedy, Mary E., RN ...
The Journal of arthroplasty,
2008, January 2008, 2008-Jan, 2008-01-00, 20080101, Letnik:
23, Številka:
1
Journal Article
Recenzirano
Abstract The mini-subvastus surgical technique avoids both quadriceps arthrotomy and patella eversion. Since March 2003, this quad-sparing minimally invasive surgical (MIS) technique has been applied ...to more than 98% of our primary total knee arthroplasty (TKA) patients. This study compares our first 150 MIS TKA patients to our previous 150 traditional TKA patients. Quadriceps recovery was rapid in the MIS group with 83% able to do a straight leg raise the day after surgery. Hospital length of stay was decreased in the MIS group, 3.4 days, vs the traditional group, 4.1 days ( P = .00013). Fewer MIS patients required skilled nursing or rehabilitation center admission. Increased knee flexion was seen for the MIS patients throughout the first 2 years of follow-up. Mean knee flexion at 1 year was 127° for the MIS patients vs 114° in the traditional TKA patients ( P < .0001). Comparison between the MIS and traditional techniques demonstrated no increase in the number or severity of complications and no difference in operating room time.
Abstract Functional deficits persist in a significant percentage of total hip arthroplasties (THA), leading to patient dissatisfaction. Spinal stenosis is a leading cause of chronic disability and ...lower extremity weakness. Although previous studies have evaluated the potential benefit of THA on back pain, none have reported the effects of spine disability on functional outcomes and patient satisfaction with THA. A total of 244 primary THAs (233 patients) with minimum 2-year follow-up rated their satisfaction, return to activity, and standard hip outcomes using the Oxford Hip Score (OHS). History of lumbar spine pain, lumbar surgery, and daily activity limitations was documented and an Oswestry Disability Index (ODI) score was calculated. Out of 244, 151 (62%) patients reported a history of back problems: 35 patients (14%)—history of lumbar surgery, 91 (37%)—daily low back pain, and 97 (40%)—back pain that limited activity. Patients with a history of back problems had lower OHS scores than those without back pain, p = 0.0001. Patients with daily low back pain or low back pain that limited activity had lower OHS scores, p < 0.0001. Increasing spine disability, as determined by ODI, correlated with poor OHS, p < 0.0001. Spine disability (ODI) was directly associated with patient dissatisfaction for pain relief ( R = 0.41, p < 0.0001), return to activity ( R = 0.34, p < 0.0001), and overall surgical results (ODI, R = 0.38, p < 0.0001) at 2 years after THA. ODI correlated strongly with poor THA outcomes. In conclusion, lumbar spine disability correlated directly with poor Oxford Hip Scores. Spine disability was directly associated with THA patient dissatisfaction with pain relief, return to activity, and overall outcome of surgery. This study demonstrates that poor functional results in THA patients correlate directly with spine disability.
Abstract The effect of increased total knee arthroplasty (TKA) surgical volume on the incidence of knee complications within a single surgeon's practice was determined. Data were collected ...prospectively on 600 primary TKAs. Major complications required knee reoperation. Minor complications were wound concerns requiring increased surveillance or oral antibiotics. Twelve major (2.0%) and 40 minor (6.7%) complications occurred at minimum 2-year follow-up. Surgical volume increased from 57 to 150 procedures per 6 months through the course of the study. Multivariate analysis determined that increased surgical volume was associated with lower rates of both major and minor complications, adjusted odds ratio 0.62 (95% confidence interval CI, 0.40-0.96) and 0.56 (95% CI, 0.43-0.73), respectively. For each additional 50 procedures performed within a 6-month interval, major complications were reduced by 38% ( P = .03), and minor complications were reduced by 44% ( P < .0001). All complications were significantly decreased when the surgeon was performing 112 ± 44 TKAs compared with 85 ± 49 TKAs per 6-month interval.
Abstract This study reviewed 747 consecutive posterior stabilized total knee arthroplasty (TKA) to explain the increased incidence of patella clunk syndrome that occurred when the surgeon switched ...from a medial parapatellar arthrotomy to a mini-subvastus (MIS) TKA technique. The incidence of patella clunk syndrome increased with increased postoperative knee flexion. Six weeks after surgery, knees that developed patella clunk had a mean flexion of 124° vs 117° for knees that did not develop this syndrome ( P = .016). As the MIS approach resulted in increased knee flexion, this approach was indirectly associated with the increased incidence of patella clunk. Knee flexion at 6 weeks postoperatively was 117° for the MIS knees vs 108° for traditional medial parapatellar arthrotomy knees ( P < .001). The effect of increased knee flexion achieved with the MIS approach, which resulted in an increase in patella clunk, was mitigated by using a new posterior stabilized femoral component designed to minimize soft tissue entrapment.
Abstract A double-blind, placebo-controlled study of a selective cyclooxygenase (COX)-2 inhibitor administered in 107 patients for 6 weeks after total knee arthroplasty was done to determine any ...benefits. All patients received celecoxib preoperatively and during hospitalization. At hospital discharge, patients were randomized to receive celecoxib or placebo for 6 weeks. Narcotic use, knee flexion, Knee Society Score, Oxford Knee Score, and Short-Form 12 scores were determined preoperatively and at postoperative intervals to 1 year. Visual analog scale scores documented pain at rest, at night, and with activities. The celecoxib group used fewer narcotics and had significantly better visual analog scale scores, knee flexion, Knee Society Score scores, Oxford Knee Score scores, and Short-Form 12 physical composite scores than the placebo group. Knee flexion remained significantly improved through 1 year. These results demonstrate that patients who took celecoxib for 6 weeks after total knee arthroplasty had a less painful and more rapid recovery.
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