Aims. Robotic-assisted total knee arthroplasty (RA-TKA) has been introduced to provide accurate bone cuts and help achieve the target knee alignment, along with symmetric gap balancing. The purpose of this study was to determine if any early clinical benefits could be realized following TKA using robotic-assisted technology. Methods. In all, 140 consecutive patients undergoing RA-TKA and 127 consecutive patients undergoing conventional TKA with minimum six-week follow-up were reviewed. Differences in visual analogue scores (VAS) for pain at rest and with activity, postoperative opiate usage, and length of stay (LOS) between the RA-TKA and conventional TKA groups were compared. Results. Patients undergoing RA-TKA had lower average VAS pain scores at rest (p = 0.001) and with activity (p = 0.03) at two weeks following the index procedure. At the six-week interval, the RA-TKA group had lower VAS pain scores with rest (p = 0.03) and with activity (p = 0.02), and required 3.2 mg less morphine equivalents per day relative to the conventional group (p < 0.001). At six weeks, a significantly greater number of patients in the RA-TKA group were free of opioid use compared to the conventional TKA group; 70.7% vs 57.0% (p = 0.02). Patients in the RA-TKA group had a shorter LOS; 1.9 days versus 2.3 days (p < 0.001), and also had a greater percentage of patient discharged on postoperative day one; 41.3% vs 20.5% (p < 0.001). Conclusion. Patients undergoing RA-TKA had lower pain levels at both rest and with activity, required less opioid medication, and had a shorter LOS

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. Methods. This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain. Results. The study group (mean visual analogue scale (VAS) pain score of 5.5 (SD 0.889)) experienced significant reduction in pain 12 hours after surgery compared to the control group (mean VAS 6.62 (SD 1.356); mean difference = 1.12, 95% confidence interval (CI) -1.46 to 0.67; p < 0.001), and pain scores on postoperative day (POD) 1 and POD-2 were lower in the study group compared to the control group (mean difference in VAS pain = 1.04 (-1.39 to -0.68, 95% CI, p < 0.001). Fewer patients in the study group (0 vs 3 in the control group) required additional analgesia for breakthrough pain, but this was not statistically significant. The study group had significantly increased active knee flexion (mean flexion 86.4° (SD 7.22°)), compared to the control group (mean 73.86° (SD 7.88°), mean difference = 12.54, 95% CI 9.97 to 15.1; p < 0.014). Conclusion. Combined ACB+ ropivacaine infusion via IAC is a safe, reproducible analgesic modality after primary TKA, with superior analgesia compared to ACB alone. Further large volume trials are warranted to generate evidence on clinical significance on analgesia after TKA. Cite this article: Bone Jt Open 2021;2(12):1082–1088

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. Methods. This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events. Results. The mean total blood loss was lowest in the no-tourniquet group at 867.32 ml (SD 201.11), increased in the limited-tourniquet group at 1024.35 ml (SD 176.35), and was highest in the tourniquet group at 1,213.00 ml (SD 211.48). The hidden blood loss was lowest in the no-tourniquet group (both p < 0.001). There was less mean intraoperative blood loss in the tourniquet group (77.48 ml (SD 24.82)) than in the limited-tourniquet group (137.04 ml (SD 26.96)) and the no-tourniquet group (212.99 ml (SD 56.35); both p < 0.001). Patients in the tourniquet group showed significantly higher levels of muscle damage and inflammation biomarkers such as CK, CRP, and IL-6 than the other two groups (p < 0.05). Outcomes for VAS pain scores, limb swelling ratio, quadriceps strength, straight leg raising, ROM, and KSS were significantly better in the no-tourniquet group at three weeks postoperatively (p < 0.05), but there were no significant differences at three months. No significant differences were observed among the three groups with respect to transfusion rate, thrombotic events, or the length of hospital stay. Conclusion. Patients who underwent TKA with multiple doses of intravenous tranexamic acid but without a tourniquet presented lower total blood loss and hidden blood loss, and they showed less postoperative inflammation reaction, less muscle damage, lower VAS pain score, and better early knee function. Our results argue for not using a tourniquet during TKA. Cite this article: Bone Joint Res 2020;9(6):322–332

Abstract. INTRODUCTION. Geniculate nerve blocks (GNB) and ablation (GNA) are increasing in popularity as strategies for the management of knee pain in patients unsuitable for surgical intervention. Typically these simple blocks have been performed by specialists in pain medicine. We present the results of a GNB clinic run by a surgical care practitioner (SCP). METHODOLOGY. An SCP clinic was created where ultrasound-guided GNBs comprising local anaesthetic and steroid were administered. Patients considered unsuitable for surgery were referred with knee pain by orthopaedic knee surgeons and specialist physiotherapists. A VAS pain score and an Oxford Knee Score (OKS) were completed prior to and immediately following blockade. Serial VAS diaries were completed. Further OKS were requested at 6 weeks and 6 months. Patients could request GNA at any point during follow-up and their follow-up ceased at this stage. RESULTS. 50 patients were identified between December 2020 and 2021. Patients are followed up until 6 months post-block or until referral for GNA. Pre-blockade mean OKS was 13.4, mean VAS 8.6, post procedure mean VAS 2.7. Six-week mean OKS was 20.9 in those not referred for ablation, mean improvement of 7.3. Of the cohort of 50, 25 have progressed to ablation. CONCLUSION. GNB is a simple procedure which can provide both lasting symptomatic relief and prognostic information in the treatment of patients with knee pain not amenable to surgical intervention, a growing subset of patients. This SCP-led clinic increases capacity for the provision of GNBs, helping to identify patients suitable for GNA

Aims. Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m. 2. (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups. Results. Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication. Conclusion. IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126–130

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 aim of this study was to assess the effectiveness of perioperative essential amino acid (EAA) supplementation to prevent rectus femoris muscle atrophy and facilitate early recovery of function after total knee arthroplasty (TKA). Methods. The study involved 60 patients who underwent unilateral TKA for primary knee osteo-arthritis (OA). This was a double-blind, placebo-controlled, randomized control trial with patients randomly allocated to two groups, 30 patients each: the essential amino acid supplementation (9 g daily) and placebo (lactose powder, 9 g daily) groups. Supplementation and placebo were provided from one week before to two weeks after surgery. The area of the rectus femoris muscle were measured by ultrasound imaging one month before surgery and one, two, three, and four weeks postoperatively. The serum albumin level, a visual analogue knee pain score, and mobility were also measured at each time point. The time to recovery of activities of daily living (ADLs) was recorded. Postoperative nutrition and physiotherapy were identical in both groups. Results. The mean relative change from baseline was as follows for the amino acid group: 116% in rectus femoris muscle area (71% to 206%); 95% in serum albumin (80% to 115%) and 39% in VAS pain (0% to 100%) at four weeks after surgery. These values in the placebo group were: 97% in muscle area (68 to 155); 89% in serum albumin (71% to 100%) and 56% in VAS pain four weeks after surgery (0% to 100%). All changes were statistically significant (p < 0.05). The mean time to recovery of ADLs was shorter in the amino acid group compared with the placebo group (p = 0.005). Conclusion. Perioperative essential amino acid supplementation prevents rectus femoris muscle atrophy and accelerates early functional recovery after TKA. Cite this article: Bone Joint J 2020;102-B(6 Supple A):10–18

Introduction. The success of total knee arthroplasty (TKA) necessitates precise osteotomies and soft tissue balancing to realign the lower extremity to a neutral mechanical axis. While technological advances have facilitated precise osteotomies, soft tissue balancing has traditionally relied mostly on surgeons’ subjective and variable tactile feedback. As soft tissue imbalance accounts for 35% of early TKA revisions in North America, we aimed to compare outcomes when TKA was balanced free-hand versus a sensor-guided balancing device (VERASENSE, OrthoSensor, Inc (Dania, FL)). Methods. In a randomized-controlled fashion, patients underwent primary TKA soft tissue balancing either free-hand or with VERASENSE (Orthosensor Inc, Dania FL) at our institution beginning January 2018. With VERASENSE, soft-tissue balancing is considered when the pressure difference between the medial and lateral knee compartments was less than 15 pounds. Data regarding patient-reported outcomes, knee range of motion (ROM), pain level, opioid consumption, inpatient ambulation distance, length of stay (LOS), and incidence of arthrofibrosis was collected and analyzed in a two-year minimum follow-up and target patient goal of 120 patients. Results. The study cohort thus far consists of 53 patients, average age 72.4 ± 8.8 years. Soft-tissue balance was conducted freehand in 23 patients and the VERASENSE was used in 30 patients. In the free-hand cohort, preoperative patient-reported outcomes for SF-12 Physical, Mental, WOMAC (pain, stiffness, function) parameters, and knee society function score (KSFS) were 39.3, 45.8, 47.7, 37.5, 48.1, and 50.0, respectively and post-operative at 3 months were 45.0, 53.0, 79.5, 72.5, 81.0, and 72.5, respectively; difference between preoperative and post-operative ROM was +8.4 degrees; average VAS pain score in the first 3 post-operative days was 2.9 ± 2.3; average opioid consumption was 100.7 ± 103.3 mg morphine equivalents; average inpatient ambulation per day was 267.9 ± 187.4 feet; average LOS was 2.3 days. In the VERASENSE cohort, patient reported outcomes for SF-12 Physical, Mental, WOMAC (pain, stiffness, function) parameters, and knee society function score (KSFS) were 38.2, 48.6, 40.1, 30.3, 40.0, and 48.7, respectively and post-operative at 3 months were 41.9, 47.6, 67.2, 59.7, 69.1, and 56.7; difference between preoperative and post-operative ROM was +3.9 degrees; average VAS pain score in the first 3 post-operative days was 2.9 ± 2.3; average opioid consumption was 105.8 ± 86.7 mg morphine equivalents; average inpatient ambulation was 384.6 ± 316.1 feet; average LOS was 2.1 days. There was no incidence of arthrofibrosis and subsequent manipulation under anesthesia in the trial. Conclusion. Short-term follow up of this randomized-controlled trial demonstrates equivalent patient-reported and clinical outcomes when soft-tissue balancing in TKA is performed free-hand versus utilization of VERASENSE, though we hypothesize a difference in the long-term

The aim of this study was to compare the efficacy of a hyaluronic acid (HA) supplement and a local anaesthetic (Bupivacaine) at providing early and short-term post-operative anagesic control following knee arthroscopy. Patients were randomised to receive either 10mls of 0.5% Bupivacaine or 10mls of HA into the joint immediately after completion of surgery. WOMAC and Tegner-Lysholm scores were obtained at baseline then at 1, 2, and 6-weeks post surgery. VAS pain scores were obtained at baseline; 1 and 24-hours; and 1, 2 and 6 weeks following surgery. 49 patients received intra-articular Bupivacaine and 49 HA. There was no statistical difference in any of the outcome measures (WOMAC, Tegner-Lysholm, VAS pain scores) at any time point between the groups overall. Patients with grade III-IV chondral defects that received HA reported significantly lower VAS pain scores at rest and movement at all time points. Use of Bupivacaine and HA intra-articular injection results in equivalent analgesic control in the immediate post-operative period and first six-weeks following surgery when administered immediately at the end of knee arthroscopy. Utilizing HA following knee arthroscopy does not sacrifice analgesic control and minimises exposure to chondrotoxic agents. Selective use of HA may improve pain-control in those with advanced chondral defects

Introduction. The addition of hydroxyapatite in cementless total knee arthroplasty is believed to reduce the time for implant fixation and rehabilitation, reduce the incidence of RLLs and provide long lasting implant stability, through improved osseointegration. We report the results of a prospective, randomised controlled single blinded study comparing the post operative pain, biological fixation and clinical outcomes with the LCS Complete Porocoat and the hydroxyapatite-coated, LCS Complete Duofix mobile-bearing knee systems. Methods. Two hundred and four patients for TKA were prospectively recruited into the study between November 2006 and November 2008. Subjects were randomly assigned to receive the LCS Complete Duofix or LCS Complete Porocoat knee systems. Outcomes including VAS pain scores, American Knee Society scores and Oxford knee scores were performed pre-operatively and at 3 months. X-rays were analysed by an independent reviewer for the presence of radiolucent lines. Results. At no time point from immediately post-operatively to 3 months post-operatively was there a statistically significant difference between groups, in terms of reduction in pain, as measured by the VAS pain score (p=0.9575). American Knee Society and Oxford Knee scores showed similar results between groups. In terms of fixation of the prostheses, radiological analysis revealed a statistical difference between the study groups, Odds Ratio 28.17 (3.670, 216.3), with Duofix having fewer radiolucent lines than Porocoat. 25% of the Porocoat tibias were assessed as not fixated at 3 months whereas only 1% of the Duofix tibias were considered not fixated. There was no significant difference in pain between the fixated and not fixated groups (p=0.293). Conclusions. The addition of hydroxyapatite did not make a significant difference in terms of pain or functional outcomes in the early post-operative period, but did reduce the incidence of radiolucent lines. The presence of radiolucent lines was not associated with increased pain

Introduction. Opioid abuse is a national epidemic. Traditional pain management after total knee arthroplasty (TKA) relied heavily on opioids. The evidence that in-hospital multimodal pain management (MMPM) is more effective than opioid-only analgesia is overwhelming. There has been little focus on post-discharge pain management. The purpose of this study was to determine whether MMPM after TKA could reduce opioid consumption in the 30-day period after hospital discharge. Methods. This was a prospective, two-arm, comparative study with a provider cross-over design. The first arm utilized a standard opioid-only (OO) prn regimen. The second arm utilized a 30-day MMPM regimen (standing doses of acetaminophen, metaxalone, meloxicam, gabapentin) and opioid medications prn. Surgeons crossed over protocols every four weeks. The primary outcome measure was VAS pain score. Secondary outcome measures included morphine milligram equivalents (MME) consumed, failure of the protocol, and manipulation under anesthesia (MUA). A pre-hoc power analysis was performed for the primary outcome measure and an intent-to-treat analysis was done utilizing a longitudinal mixed model. Results. There were 43 patients in the OO cohort and 39 patients in the MMPM cohort. There was no difference in the baseline demographics or preoperative scores (p=0.94). There was no clinically meaningful difference in VAS score between the two groups at any time. The average opioid consumption at 30-days was 469 and 344 MME's for the OO and MMPM cohorts, respectively (p=0.026). 19/43 (44.2%) patients in the OO cohort failed vs. 4/39 (10.3%) in the MMPM cohort (p=0.002). There was 1 MUA in the OO and none in the MMPM cohort (p=0.338). Discussion. A 30-day post-discharge multimodal pain regimen reduced opioid use after TKA. Opioid-only regimens are at an increased risk of failure to control pain. As a result of this study, multimodal pain management after hospital discharge is standard at our institution

Aims

Unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) have both been shown to be effective treatments for osteoarthritis (OA) of the knee. Many studies have compared the outcomes of the two treatments, but less so with the use of robotics, or individualized TKA alignment techniques. Functional alignment (FA) is a novel technique for performing a TKA and shares many principles with UKA. Our aim was to compare outcomes from a case-matched series of robotic-assisted UKAs and robotic-assisted TKAs performed using FA.

Aims

The aim of this study was to determine whether obesity had a detrimental effect on the long-term performance and survival of medial unicompartmental knee arthroplasties (UKAs).

Aims

Knee osteoarthritis (OA) is characterized by a chronic inflammatory process involving multiple cytokine pathways, leading to articular cartilage degeneration. Intra-articular therapies using pharmaceutical or autologous anti-inflammatory factors offer potential non-surgical treatment options. Autologous protein solution (APS) is one such product that uses the patient’s blood to produce a concentrate of cells and anti-inflammatory cytokines. This study evaluated the effect of a specific APS intra-articular injection (nSTRIDE) on patient-reported outcome measures compared to saline in moderate knee OA.

Aims

The aim of this study was to compare a bicruciate-retaining (BCR) total knee arthroplasty (TKA) with a posterior cruciate-retaining (CR) TKA design in terms of kinematics, measured using fluoroscopy and stability as micromotion using radiostereometric analysis (RSA).

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

Access to total knee arthroplasty (TKA) is sometimes restricted for patients with severe obesity (BMI ≥ 40 kg/m²). This study compares the cost per quality-adjusted life year (QALY) associated with TKA in patients with a BMI above and below 40 kg/m² to examine whether this is supported.

Aims

Both the femoral and tibial component are usually cemented at revision total knee arthroplasty (rTKA), while stems can be added with either cemented or press-fit (hybrid) fixation. The aim of this study was to compare the long-term stability of rTKA with cemented and press-fitted stems, using radiostereometric analysis (RSA).

Aims

Platelet-rich plasma (PRP) intra-articular injections may provide a simple and minimally invasive treatment for early-stage knee osteoarthritis (OA). This has led to an increase in its adoption as a treatment for knee OA, although there is uncertainty about its efficacy and benefit. We hypothesized that patients with early-stage symptomatic knee OA who receive multiple PRP injections will have better clinical outcomes than those receiving single PRP or placebo injections.

Aims

The aims of this study were to investigate the ability to kneel after total knee arthroplasty (TKA) without patellar resurfacing, and its effect on patient-reported outcome measures (PROMs). Secondary aims included identifying which kneeling positions were most important to patients, and the influence of radiological parameters on the ability to kneel before and after TKA.