There is conflicting evidence about the benefit of using corticosteroid in periarticular injections for pain relief after total knee arthroplasty (TKA). We carried out a double-blinded, randomised controlled trial to assess the efficacy of using corticosteroid in a periarticular injection to control pain after TKA. . A total of 77 patients, 67 women and ten men, with a mean age of 74 years (47 to 88) who were about to undergo unilateral TKA were randomly assigned to have a periarticular injection with or without corticosteroid. The primary outcome was post-operative pain at rest during the first 24 hours after surgery, measured every two hours using a visual analogue pain scale score. The cumulative pain score was quantified using the area under the curve. . The corticosteroid group had a significantly lower cumulative pain score than the no-corticosteroid group during the first 24 hours after surgery (mean area under the curve 139, 0 to 560, and 264, 0 to 1460; p = 0.024). The rate of complications, including surgical site infection, was not significantly different between the two groups up to one year post-operatively. . The addition of corticosteroid to the periarticular injection significantly decreased early post-operative pain. Further studies are needed to confirm the safety of corticosteroid in periarticular injection. Take home message: The use of corticosteroid in periarticular injection offered better pain relief during the initial 24 hours after TKA. Cite this article: Bone Joint J 2016;98-B:194–200

Aims. 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. Patients and Methods. 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. Results. There were no statistically significant differences between the groups in relation to: VAS pain scores in the first 24 hours post-operatively (p = 0.693), the use of morphine in the PCA (p = 0.647), blood loss (p = 0.625), and length of stay (p = 0.17). There were no neurovascular complications in either group. Conclusion. The multimodal infiltration of local anaesthetic with infiltration of the posterior capsule did not provide significant added analgesic benefits or reduce the use of morphine after TKA. Multimodal infiltration is a satisfactory technique for the management of pain in these patients without the attendant risks of PCI. Cite this article: Bone Joint J 2017; 99-B:483–8

Aims. Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anaesthesia in primary TKAs from a single, high-volume academic centre. Methods. We retrospectively identified 17,690 primary TKAs (13,297 patients) from 2001 to 2016 using our institutional total joint registry, where 52% had general anaesthesia and 48% had spinal anaesthesia. Baseline characteristics were similar between cohorts with a mean age of 68 years (SD 10), 58% female (n = 7,669), and mean BMI of 32 kg/m. 2. (SD 7). Pain was evaluated using oral morphine equivalents (OMEs) and numerical pain rating scale (NPRS) data. Complications including 30- and 90-day readmissions were studied. Data were analyzed using an inverse probability of treatment weighted model based on propensity score that included many patient and surgical factors. Mean follow-up was seven years (2 to 18). Results. Patients treated with spinal anaesthesia required fewer postoperative OMEs (p < 0.001) and had lower NPRS scores (p < 0.001). Spinal anaesthesia also had fewer cases of altered mental status (AMS; odds ratio (OR) 1.3; p = 0.044), as well as 30-day (OR 1.4; p < 0.001) and 90-day readmissions (OR 1.5; p < 0.001). General anaesthesia was associated with increased risk of any revision (OR 1.2; p = 0.021) and any reoperation (1.3; p < 0.001). Conclusion. In the largest single institutional report to date, we found that spinal anaesthesia was associated with significantly lower OME use, lower risk of AMS, and lower overall 30- and 90-day readmissions following primary TKAs. Additionally, spinal anaesthesia was associated with reduced risk of any revision and any reoperation after accounting for numerous patient and operative factors. When possible and safe, spinal anaesthesia should be considered in primary TKAs. Cite this article: Bone Joint J 2022;104-B(11):1209–1214

Abstract. Introduction. To compare the efficacy of adductor canal blocks (ACB) and periarticular anesthetic injections (PAI) with bupivacaine in total knee arthroplasty. Methods. 90 patients undergoing primary total knee arthroplasty under spinal anesthesia were randomized to 1 of 3 groups: ACB alone (15 mL of 0.5% bupivacaine), PAI alone (50 mL of 0.25% bupivacaine with epinephrine) and ACB + PAI. Primary outcome in this study was the visual analog scale (VAS) pain score in the immediate postoperative period. Secondary outcomes included postoperative opioid use, activity level during physiotheraphy, length of hospital stay and ROM. Results. Mean VAS pain score was significantly higher with ACB alone, compared with the score after use of ACB+PAI, on POD1 and POD3. Total opioid consumption through POD3 was significantly higher when ACB alone had been used compared with PAI alone and ACB+PAI. Opioid consumption in the ACB-alone group was significantly higher than that in the ACB + PAI group on POD2 and POD3 and significantly higher than that in the PAI alone group on POD2. There was no significant difference in opioid consumption between the patients treated with PAI alone and those who received ACB + PAI. The activity level during physiotherapy on POD0 was significantly lower after use of ACB alone than after use of PAI alone or ACB + PAI. Conclusion. Higher pain scores after total knee arthroplasty done with an ACB and without PAI, suggesting that ACB alone is inferior for perioperative pain control. There were no significant differences between ACB alone, PAI alone and ACB + PAI inparameters measured

Aims. The purpose of this study was to use pharmacogenetics to determine the frequency of genetic variants in our total knee arthroplasty (TKA) patients that could affect postoperative pain medications. Pharmacogenetic testing evaluates patient DNA to determine if a drug is expected to have a normal clinical effect, heightened effect, or no effect at all on the patient. It also predicts whether patients are likely to experience side effects from medicine. We further sought to determine if changing the multimodal programme based on these results would improve pain control or reduce side effects. Methods. In this pilot study, buccal samples were collected from 31 primary TKA patients. Pharmacogenetics testing examined genetic variants in genes OPRM1, CYP1A2, CYP2B6, CYP2C19, CYP3A4, CYP2C9, and CYP2D6. These genes affect the pharmacodynamics and pharmacokinetics of non-steroidal anti-inflammatory drugs and opioids. We examined the frequency of genetic variants to any of the medications we prescribed including celecoxib, hydrocodone, and tramadol. Patients were randomized to one of two groups: the control group received the standard postoperative pain regimen, and the study group received a customized regimen based on the pharmacogenetic results. For the first ten postoperative days, patients recorded pain scores, medication, and side effects. Results. Genetic variants involving one or more medications in the multimodal pain protocol occurred in 13 of the 31 patients (42%). In total, eight patients (26%) had variants affecting more than one of the medications. For the 25 patients who recorded pain and medication logs, the mean pain levels and morphine equivalents (MEQs) consumed in the first ten days were higher in the control group than in the custom-guided group (p = 0.019 for pain and p = 0.655 for MEQ). Conclusion. Overall, 42% of patients had a variant involving one of the pain medications prescribed in our perioperative pain program for TKA. Ongoing research will help determine if using these data to modify a patient’s medication will improve outcomes. Cite this article: Bone Joint J 2020;102-B(6 Supple A):73–78

Aims

The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources.

Aims

To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

Introduction. Insufficient pain control following lower extremity surgery can increase length of stay, readmission rates, and impair postoperative outcome. It has been shown that CYP2D6 genotypes predict function of the enzyme responsible for conversion of hydrocodone to hydromorphone (active metabolite) and plasma concentration of hydromorphone best predicted analgesic response. Purpose of this study was to evaluate relationship of CYP2D6 genotypes, drug-drug interactions, and plasma drug concentrations in patients undergoing lower extremity surgery. Methods. A prospective cohort of 271 orthopedic patients undergoing lower extremity surgery including TKA, THA and trauma were queried. Patients treated with hydrocodone were enrolled and tested for plasma concentrations of hydrocodone and hydromorphone. CYP2D6 genotyping was performed. Medications co-administered with hydrocodone during perioperative and postoperative periods were queried. Results. Out of 271 patients enrolled, only 41 (15%) had detectable hydromorphone (i.e. >0.5 ng/mL). 86% were extensive (normal) metabolizers, 7% were intermediate metabolizers, 5% poor metabolizers and 2% were ultra rapid metabolizers. 179 subjects were not administered any inhibitors of CYP2D6 whereas 92 were on at least one inhibitor. 33 (18%) with no pharmacological inhibitors had detectable hydromorphone, whereas only 7 (7.6%) on inhibitors had hydromorphone detected above the lower limit of quantification (0.5ng/mL), p=0.033. Diphenhydramine, fluoxetine, hydralazine, duloxetine, bupropion and sertraline, were the most common CYP2D6 inhibitors co-administered with hydrocodone in this cohort. Conclusions. Patients' home medications and selection of various drugs in the postoperative setting could impact the pharmacokinetics and pharmacodynamics of hydrocodone leading to a diminished analgesic response. We conclude that health care providers should become familiar with the inhibitors of CYP2D6 to obtain the best response with the use of hydrocodone following lower extremity surgery. Additional work is required to determine the ideal opioid for an individual patient's genotype following lower extremity orthopedic surgery. For figures, tables, or references, please contact authors directly

Introduction. Even as the outcomes of primary total knee arthroplasty (TKA) continue to improve, there remain increasing concerns about pain control after surgery and prolonged narcotic use. Cryoneurolysis has been demonstrated to reduce osteoarthritis knee pain for up to 90 days. We hypothesized that postoperative narcotic use could be reduced following preoperative cryoneurolysis of the superficial genicular nerves. Methods. Primary TKA patients were randomized into either a control or cryoneurolysis treatment group. Both followed the same preoperative, intraoperative, and postoperative pain management protocol, except the treatment group had cryoneurolysis of their superficial genicular nerves 3–7 days prior to surgery. All patients were prescribed 40 narcotic pills at discharge and pills were counted at 72 hours and at 2,6, and 12 weeks postoperatively. The primary endpoint was daily morphine equivalent (DME) based on pill count and secondary endpoints were changes in pain and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, Jr.) scores. Results. Per-protocol results demonstrated that the DME for the treatment group was significantly lower at 72 hours (10.9 mg vs. 14.9 mg, p=0.0389), 6 weeks (4.2 mg vs. 5.9 mg, p=0.0186) and 12 weeks (2.4 mg vs 3.4 mg p=0.0234). Overall, there was a 29% reduction in the DMEs over the entire 12-week postoperative period. Only 14% of the treatment group consumed opioids past 6 weeks compared to 44% of the control group (p=0.0005). The treatment group demonstrated a greater reduction in pain scores from baseline at 72 hours and 12 weeks. The treatment group also showed significant improvements in KOOS Jr. scores compared to the control group at all timepoints. Conclusions. The results demonstrate that preoperative cryoneurolysis can reduce opioid consumption after TKA. The early cessation of opioid consumption is especially encouraging given the association of prolonged narcotic use with increased complications following surgery. Preoperative cryoneurolysis should be considered as part of a multimodal protocol to reduce opioid consumption and pain and improve function after TKA. For figures, tables, or references, please contact authors directly

Introduction. Controlling post-operative pain and reducing opioid requirements after total knee arthroplasty (TKA) remains a challenge, particularly in an era stressing rapid recovery protocols and early discharge. A single shot adductor canal block (ACB) has been shown to be effective in decreasing post-operative pain. This requires a specialty-trained Anesthesiologist skilled in ultrasound techniques, which imposes cost, time and skill barriers. Cadaveric studies and magnetic resonance imaging data have shown that access to the adductor canal is possible from within the joint, and thus the potential for intraoperative, intra-articular, surgeon administered ACB through a standard surgical approach is a feasible alternative to ultrasound guided ACB at the time of TKA. The purpose of the present study is to compare the efficacy of surgeon administered intraoperative ACB to anesthesiologist administered ACB. Methods. Patients' undergoing primary TKA were prospectively randomized to receive either an Anesthesiologist administered (Group 1) or Surgeon administered (Group 2) ACB using 15 ml of Ropivacaine 0.5%, both in conjunction with spinal anesthesia. Perioperative multimodal anesthesia was standardized for the two groups. Primary outcomes were pain visual analogue scale (VAS), range of motion, and opioid consumption. Secondary outcomes were patient satisfaction scores and length of stay (LOS). Results. 51 patients were enrolled and followed for a minimum of 6 weeks. 28 were randomized to Group 1 and 23 to Group 2. Opioid equivalents consumed were equal on POD 0,1, and 2 (p=0.86, 0.68, 0.47). Patients in Group 1 had significantly less pain on POD 0 [46.9 vs 61.8] (p=0.014), but there was no difference in pain on POD 1 or 2 (p=0.4, p=0.95). There was no difference in active flexion on post-operative day (POD) 0, POD 1 or 6 weeks post op (p=0.86, 0.074 and 0.59) and no difference in active extension on POD 0, 1, or 6 weeks (p=0.38,0.07and p=0.3). There was no difference in patient satisfaction with pain control on POD 0, 1, or 2 (p=0.6, p=0.7, p=0.9). There was no difference in LOS (1.3 vs 1.4 days p=0.34). Conclusion. Surgeon administered ACB is not inferior to Anesthesiologist administered ACB with respect to range of motion, patient satisfaction, or opioid consumption, although pain on the day of surgery may be greater. Surgeon administered ACB is an effective and cost- and time- efficient alternative to Anesthesiologist administered ACB. For figures, tables, or references, please contact authors directly

Introduction. Pharmacogenetics evaluates a patient's DNA to determine if a particular drug is expected to have a normal clinical effect, heightened effect, or no effect at all on a patient. It may also predict which patients are most likely to experience side effects from the medications. The purpose of this study was to use pharmacogenetic testing to determine how frequently total knee arthroplasty (TKA) patients have genetic variants to standard postoperative pain medications. We further sought to determine if changing the multimodal program based on these results would improve pain control and reduce side effects. Methods. In this prospective, randomized study, buccal cheek swab samples were collected from 31 primary TKA patients. Pharmacogenetics testing was performed on the samples to examine genetic variants in genes OPRM1, CYP1A2, CYP2B6, CYP2C19, CYP3A4, CYP2C9, and CYP2D6. These genes affect the pharmacodynamics and pharmacokinetics of NSAIDs and opioids. We examined the frequency of a genetic variant to one of the multimodal medications we prescribe including celecoxib, hydrocodone, and tramadol. Subjects included 9 men and 22 women. Patients were randomized to one of two groups: the control group received the standard postoperative pain regimen; the study group received a customized regimen based on the pharmacogenetic results. For the first 10 postoperative days patients recorded pain scores, amount of pain medication taken, and any side effects experienced. Results. Genetic variations to one or more medications in our standard postoperative pain management protocol occurred in 13 of the 31 patients (42%). 8 patients (26%) had a variation of gene CYP2C9 affecting celecoxib. 11 patients (35%) had a variation of gene OPRM1 and/or CYP2D6 affecting the response to hydrocodone. 4 patients (13%) had a variation of gene CYP2D6 that altered their response to tramadol. Of the 31 patients tested, only 18 (58%) had no genetic variants related to the pain medications we routinely prescribe. 8 patients (26%) had variants affecting more than one of the medications. (Table 1, below) Both the average pain levels and morphine equivalents consumed in the first 10 days were higher in the control group than in the study group. Conclusion. 42% of patients in this study demonstrated a pharmacogenetic variant to one of the commonly used multimodal pain medications. Our early data suggests that customizing pain regimens based on this information can help reduce pain and the amount of pain medication used postoperatively. For figures, tables, or references, please contact authors directly

Aims

Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone.

Aims. Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Methods. On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. Results. A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). Conclusion. The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J 2021;103-B(6 Supple A):102–107

Aims

The primary aim of this study was to compare the postoperative systemic inflammatory response in conventional jig-based total knee arthroplasty (conventional TKA) versus robotic-arm assisted total knee arthroplasty (robotic TKA). Secondary aims were to compare the macroscopic soft tissue injury, femoral and tibial bone trauma, localized thermal response, and the accuracy of component positioning between the two treatment groups.

This review considers the surgical treatment of displaced fractures involving the knee in elderly, osteoporotic patients. The goals of treatment include pain control, early mobilisation, avoidance of complications and minimising the need for further surgery. Open reduction and internal fixation (ORIF) frequently results in loss of reduction, which can result in post-traumatic arthritis and the occasional conversion to total knee replacement (TKR). TKR after failed internal fixation is challenging, with modest functional outcomes and high complication rates. TKR undertaken as treatment of the initial fracture has better results to late TKR, but does not match the outcome of primary TKR without complications. Given the relatively infrequent need for late TKR following failed fixation, ORIF is the preferred management for most cases. Early TKR can be considered for those patients with pre-existing arthritis, bicondylar femoral fractures, those who would be unable to comply with weight-bearing restrictions, or where a single definitive procedure is required

Aims

The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid.

Aims

Enhanced perioperative protocols have significantly improved patient recovery following primary total knee arthroplasty (TKA). Little has been investigated the effectiveness of these protocols for revision TKA (RTKA). We report on a matched group of aseptic revision and primary TKA patients treated with an identical pain and rehabilitation programmes.

Purpose of Study. In this review, we present the data of one of the largest non-designer, mid- to long-term follow-ups of the AGC carried out by surgeons of differing grades and sub-specialty. Summary of methods and Results. We present a total of 1538 AGC knees during a 15 year period, of which 902 were followed up by postal or telephone questionnaire focused on Oxford Knee Scores, Visual analogues of function and pain and survival analyses performed. 85.7% of patients had an Oxford knee score of between 0 and 40, with 71.2% scoring between 0 - 30. 65.6% of patients responded with a Visual Analogue Score (VAS) of 0 or 1 at rest (minimum pain = 0) and 53.9% reporting VA scores of 0 or 1 while walking. 87.5% of patients reported Excellent or good functional reports at final follow up and 90.3% reporting excellent or good pain control compared to per-operative levels. There is a survivorship of 95.88% at 15years. This large cohort and multi-surgeon & multi-experience level trial reproduces the excellent results as demonstrated by the designer centre (Ritter et al.) and is better than most others in the literature. Mid to long term outcome shows excellent function and analgesia. Complication rates are low and the necessity for revision remains low. Conclusion. In the hands of most orthopaedic surgeons, the AGC knee continues to deliver reproducible and satisfactory results and have good survivorship

Our aim in this audit was to determine whether intensive rehabilitation post-operatively influenced length of stay and readmission rates for patients undergoing primary total knee arthroplasty. In September 2007, a dedicated weekend physiotherapy service was set up in our Trust for patients following joint arthroplasty at a cost of £30,000 per annum. A prospective audit was conducted over two six-month periods, before and after the introduction of this service, including 202 and 240 patients respectively. Patient demographics including ASA grade and strict inclusion and exclusion criteria were used. The effect of anaesthetic type on post-operative pain control was also reviewed. Chi-squared and Mann-Whitney tests were used to analyse non-parametric data. In the second cohort, with intensive rehabilitation, a statistically significantly higher number of patients were discharged within seven days of admission (64% vs 36%, p<0.01). This was despite there being a significantly higher number of patients with high ASA grades 3-4 in this cohort (37% vs 27%, p<0.05). The median length of stay in the second cohort was seven days compared to eight in the first cohort. There was a slight increase in rate of readmission within the second cohort but this was not statistically significant. We found that the addition of a femoral nerve block significantly reduced post-operative pain. We concluded that an annual financial saving to the Trust of approximately £118,000 could be made by the addition of an additional dedicated physiotherapist in our unit. Patients can be safely discharged sooner with intensive rehabilitation and may benefit in the longer term by improved knee function

Aims

The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA).