In a randomised controlled pragmatic trial we
investigated whether local infiltration analgesia would result in earlier
readiness for discharge from hospital after total knee replacement
(TKR) than patient-controlled epidural analgesia (PCEA) plus femoral
nerve block. A total of 45 patients with a mean age of 65 years
(49 to 81) received a local infiltration with a peri-articular injection
of bupivacaine, morphine and methylprednisolone, as well as adjuvant
analgesics. In 45 PCEA+femoral nerve blockade patients with a mean
age of 67 years (50 to 84), analgesia included a bupivacaine nerve
block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics.
The mean time until ready for discharge was 3.2 days (1 to 14) in
the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral
nerve blockade group. The mean pain scores for patients receiving
local infiltration were higher when walking (p = 0.0084), but there
were no statistically significant differences at rest. The mean
opioid consumption was higher in those receiving local infiltration. The choice between these two analgesic pathways should not be
made on the basis of time to discharge after surgery. Most secondary
outcomes were similar, but PCEA+femoral nerve blockade patients
had lower pain scores when walking and during continuous passive
movement. If PCEA+femoral nerve blockade is not readily available, local
infiltration provides similar length of stay and similar pain scores
at rest following TKR. Cite this article:
Background. There are limited data on the complication rates and risk of periprosthetic joint infection (PJI) in patients who have an acute wound dehiscence after total knee arthroplasty (TKA). Methods. From 2002 to 2018, 16,134 primary TKAs were performed at a single institution. Twenty-six patients (0.1%) had a traumatic wound dehiscence within the first 30 days. Mean age was 68, 38% were female, and mean BMI was 33 kg/m2. Median time to dehiscence was 13 days. The dehiscence resulted from a fall in 22 cases, including 4 in-hospital falls (3 with
Intra-operative, peri-articular injection of
local anaesthesia is an increasingly popular way of controlling
pain following total knee replacement. At the same
time, the problems associated with allogenic blood transfusion have led
to interest in alternative methods for managing blood loss after
total knee replacement, including the use of auto-transfusion of
fluid from the patient’s surgical drain. It is safe to combine peri-articular
infiltration with auto-transfusion from the drain. We performed
a randomised clinical trial to compare the concentration of local anaesthetic
in the blood and in the fluid collected in the knee drain in patients
having either a peri-articular injection or a femoral nerve block.
Clinically relevant concentrations of local anaesthetic were found
in the fluid from the drains of patients having peri-articular injections
(4.92 μg/ml (. sd. 3.151)). However, none of the patients
having
To describe the risk of periprosthetic joint infection (PJI) and reoperation in patients who have an acute, traumatic wound dehiscence following total knee arthroplasty (TKA). From January 2002 to December 2018, 16,134 primary TKAs were performed at a single institution. A total of 26 patients (0.1%) had a traumatic wound dehiscence within the first 30 days. Mean age was 68 years (44 to 87), 38% (n = 10) were female, and mean BMI was 34 kg/m2 (23 to 48). Median time to dehiscence was 13 days (interquartile range (IQR) 4 to 15). The dehiscence resulted from a fall in 22 patients and sudden flexion after staple removal in four. The arthrotomy was also disrupted in 58% (n = 15), including a complete extensor mechanism disruption in four knees. An irrigation and debridement with component retention (IDCR) was performed within 48 hours in 19 of 26 knees and two-thirds were discharged on antibiotic therapy. The mean follow-up was six years (2 to 15). The association of wound dehiscence and the risk of developing a PJI was analyzed.Aims
Methods
The aim of this study was to compare the effectiveness of a femoral
nerve block and a periarticular infiltration in the management of
early post-operative pain after total knee arthroplasty (TKA). A pragmatic, single centre, two arm parallel group, patient blinded,
randomised controlled trial was undertaken. All patients due for
TKA were eligible. Exclusion criteria included contraindications
to the medications involved in the study and patients with a neurological
abnormality of the lower limb. Patients received either a femoral
nerve block with 75 mg of 0.25% levobupivacaine hydrochloride around
the nerve, or periarticular infiltration with 150 mg of 0.25% levobupivacaine
hydrochloride, 10 mg morphine sulphate, 30 mg ketorolac trometamol
and 0.25 mg of adrenaline all diluted with 0.9% saline to make a
volume of 150 ml.Aims
Patients and Methods
The aim of this study was to evaluate the effects of using a
portable, accelerometer-based surgical navigation system (KneeAlign2)
in total knee arthroplasty (TKA) on the alignment of the femoral
component, and blood loss. A total of 241 consecutive patients with primary osteoarthritis
of the knee were enrolled in this prospective, randomised controlled
study. There were 207 women and 34 men. The mean age of the patients
was 74.0 years (57 to 89). The KneeAlign2 system was used for distal
femoral resection in 121 patients (KA2 group) and a conventional intramedullary
femoral guide was used in 120 patients (IM group).Aims
Patients and Methods
Unicompartmental knee arthroplasty (UKA) has been successfully
performed in the United States healthcare system on outpatients.
Despite differences in healthcare structure and financial environment,
we hypothesised that it would be feasible to replicate this success
and perform UKA with safe day of surgery discharge within the NHS,
in the United Kingdom. This has not been reported in any other United
Kingdom centres. We report our experience of implementing a pathway to allow safe
day of surgery discharge following UKA. Data were prospectively
collected on 72 patients who underwent UKA as a day case between
December 2011 and September 2015. Aims
Patients and Methods
Multimodal infiltration of local anaesthetic provides effective
control of pain in patients undergoing total knee arthroplasty (TKA).
There is little information about the added benefits of posterior
capsular infiltration (PCI) using different combinations of local
anaesthetic agents. Our aim was to investigate the effectiveness
of the control of pain using multimodal infiltration with and without
infiltration of the posterior capsule of the knee. In a double-blind, randomised controlled trial of patients scheduled
for unilateral primary TKA, 86 were assigned to be treated with
multimodal infiltration with (Group I) or without (Group II) PCI.
Routine associated analgesia included the use of bupivacaine, morphine,
ketorolac and epinephrine. All patients had spinal anaesthesia and patient-controlled
analgesia (PCA) post-operatively. A visual analogue scale (VAS)
for pain and the use of morphine were recorded 24 hours post-operatively.
Side effects of the infiltration, blood loss, and length of stay
in hospital were recorded.Aims
Patients and Methods
Controversy remains regarding the optimal post-operative
analgesic regimen following total knee replacement. A delicate balance
is required between the provision of adequate pain relief and early
mobilisation. By reviewing 29 randomised trials we sought to establish
whether local infiltration of analgesia directly into the knee during
surgery provides better pain relief and a more rapid rehabilitation.
Although we were able to conclude that local infiltration can provide
improved post-operative pain relief, and to suggest the most promising
technique of administration, there is no evidence that it reduces
hospital stay.
A prospective, randomised, controlled trial compared two different techniques of high tibial osteotomy with a lateral closing wedge or a medial opening wedge, stabilised by a Puddu plate. The clinical outcome and radiological results were examined at one year. The primary outcome measure was the achievement of an overcorrection of valgus of 4°. Secondary outcome measures were the severity of pain (visual analogue scale), knee function (Hospital for Special Surgery score), and walking distance. Between January 2001 and April 2004, 92 patients were randomised to one or other of the techniques. At follow-up at one year the post-operative hip-knee-ankle angle was 3.4° (± 3.6° The severity of pain, knee score and walking ability improved in both groups, but the difference was not significant. Because of pain, the staples required removal in 11 (23%) patients in the closing-wedge group and a Puddu plate was removed in 27 (60%) patients in the opening-wedge group. This difference was significant (p <
0.001). We conclude that closing-wedge osteotomy achieves a more accurate correction with less morbidity, although both techniques had improved the function of the knee at one year after the procedure.
