Femoral Nerve Block versus Adductor Canal Block for Analgesia after Total Knee Arthroplasty

Inadequate pain management after total knee arthroplasty (TKA) impedes recovery, increases the risk of postoperative complications, and results in patient dissatisfaction. Although the preemptive use of multimodal measures is currently considered the principle of pain management after TKA, no gold standard pain management protocol has been established. Peripheral nerve blocks have been used as part of a contemporary multimodal approach to pain control after TKA. Femoral nerve block (FNB) has excellent postoperative analgesia and is now a commonly used analgesic modality for TKA pain control. However, FNB leads to quadriceps muscle weakness, which impairs early mobilization and increases the risk of postoperative falls. In this context, emerging evidence suggests that adductor canal block (ACB) facilitates postoperative rehabilitation compared with FNB because it primarily provides a sensory nerve block with sparing of quadriceps strength. However, whether ACB is more appropriate for contemporary pain management after TKA remains controversial. The objective of this study was to review and summarize recent studies regarding practical issues for ACB and comparisons of analgesic efficacy and functional recovery between ACB and FNB in patients who have undergone TKA.

Is Routine Thromboprophylaxis Needed in Korean Patients Undergoing Unicompartmental Knee Arthroplasty?

This study was undertaken to determine the prevalence and the natural course of venous thromboembolism (VTE) without thromboprophylaxis to ascertain whether routine thromboprophylaxis is necessary following unicompartmental knee arthroplasty (UKA) in Korean patients. The medical records and multidetector row computed tomography (MDCT) imaging of the consecutive 77 UKAs in 70 patients were reviewed. In all patients, MDCTs were undertaken preoperatively and at 1-week after surgery, and VTE symptoms were evaluated. At postoperative 6-months, follow-up MDCTs were undertaken in all patients in whom VTEs were newly detected after surgery. VTE lesions were newly detected in 18 (26%) of the 70 patients. However, none of the patients complained of VTE-related symptoms and MDCT demonstrated that all VTEs were small and involved limited portion without lower leg edema or pleuroparenchymal complication. At the 6-month follow up MDCT, all types of VTEs were shown to be completely resolved, regardless of their location. All of the VTE lesions maintained an asymptomatic status for 6-month after surgery. VTE following UKA in Korean patients who do not receive thromboprophylaxis seems to occur frequently, but all of the VTEs are clinically insignificant and all VTEs are spontaneously regressed. Routine thromboprophylaxis or thrombolytic treatment in Korean patients undergoing UKA may not be necessary.

Two- to Four-Year Follow-up Results of Total Knee Arthroplasty Using a New High-Flexion Prosthesis

PURPOSE: The purpose of this study was to evaluate minimum 2-year follow-up results of total knee arthroplasty (TKA) performed using a new high-flexion prosthesis design (LOSPA). MATERIALS AND METHODS: The 2- to 4-year results of 191 consecutive TKAs (177 patients) with the LOSPA posterior-stabilized prosthesis were evaluated. The patients were assessed clinically and radiographically using the Knee Society scoring system (KSS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). RESULTS: The mean range of motion (ROM) increased significantly from 117.4degrees (range, 75degrees to 140degrees) preoperatively to 126.7degrees (range, 80degrees to 144degrees) postoperatively (p<0.001). The mean KSS and WOMAC scores improved significantly from 121.4 (range, 42 to 185) and 56.1 (range, 23 to 88) preoperatively to 174.0 (range, 130 to 200) and 16.4 (range, 0 to 85) postoperatively, respectively (both, p<0.001). One knee required revision for deep infection. No knee had aseptic loosening or osteolysis. Radiolucent lines were noted in 15 knees (7.9%). CONCLUSIONS: The new high-flexion total knee prosthesis resulted in no early aseptic loosening of the component and improved postoperative ROM comparable to other high-flexion TKA prostheses at 2- to 4-year follow-ups.

Effect of Regional Nerve Block in Total Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: The goal of this study is to evaluate the efficacy of femoral, obturator, and sciatic nerve regional blocks with using ropivacaine during total knee arthroplasty. MATERIALS AND METHODS: As a prospective study, we performed total knee arthroplasty for 383 patients from Oct. 2004 to Feb. 2009. There was 139 cases of femoral and obturator nerve regional block, 123 cases of femoral, obturator, and sciatic nerve regional block, and 121 cases of lidocaine local anesthesia at the synovium and subcutaneous tissue during wound closure. All the femoral nerve block cases used a femoral catheter for an additional ropivacaine injection at 10 hours after surgery. The pain was examined using a visual analogue scale (VAS). The VAS scores were checked on the day of surgery and at post operative 24 hours, 48 hours and 6 days. The pain control effects among the 3 groups were compared with one-way ANOVA test and Scheffe`s multiple comparison test. RESULTS: The mean postoperative VAS score on the day of surgery and at post operative 24 hours, 48 hours and 6 days in the femoral and obturator nerve block group, were 6.3, 5.6, 5.3, and 4.7, respectively. For the cases of femoral, obturator and sciatic nerve block, the VAS scores were 3.9, 4.3, 3.5 and 1.9, respectively, and the VAS scores in the lidocaine local anesthetic group were 7.1, 6.1, 5.8 and 5.2, respectively. There was a statistical significance in all three groups (p<.0001), and the additional sciatic nerve block groups had significant effectiveness. CONCLUSION: Pain control with the ropivacaine regional nerve block is more effective than the lidocaine local anesthesia, and additional sciatic nerve block is a important factor for decreasing the postoperative pain after total knee arthroplasty.

A Novel Autogenous Iliac Bone Graft Technique for Distal Humeral Bone Loss in Revisional Total Elbow Arthroplasty: A Technical Note / 대한정형외과학회잡지

As the incidence of total elbow arthroplasty has increased, revisions of the procedure also increase including reconstruction of bony defects caused by bone destruction. Reconstruction techniques depend on location and severity of the bony defect, and allografts are useful in cases of substantial bone loss. However, this procedure is technically difficult and has a high complication rate. Here, we describe a novel autogenous bone graft technique using tricortical iliac bone for reconstruction of a distal bone loss in a revisional total elbow arthroplasty, providing an additional method to restore bone stock.

Operative Treatment of Patellar Fractures

PURPOSE: To establish a general guide line in the treatment of the patellar fracture MATERIALS AND METHODS: Twenty three patellar fractures followed for 2.2 years in average, treated with internal fixation were evaluated retrospectively. The primary fixations were the metal screw fixation in 7, the Dall-Miles' cable circumferential fixation in 14 and combination of both methods in 2 cases. The additional fixations were the tension band wiring in 9, the load sharing cable fixation in 3 and combination of both methods in 5 cases. The initial postoperative immobilazation of the knee joint in flexion, preferably 90degrees, for 7 days was effective to gain full range of motion RESULTS: Complete union without displacement was achieved in all cases. Full ROM was achieved in all cases except one. CONCLUSION: The choice of internal fixation need to be individualized according to the level of comminution, bone strength, fracture site and soft tissue damage. A strong internal fixation, initial immobilization in flexion followed by early ROM exercise were important factors to gain good result.

Open Reduction of Developmental Dislocation of the Hip in Patients Older than Eight Years / 대한정형외과학회잡지

PURPOSE: To evaluate the outcome and effectiveness of an open reduction in DDH for the patients 8 years and older. MATERIALS AND METHODS: Fourteen patients older than 8 years and diagnosed with DDH were treated by an open reduction, femoral shortening, and varus derotational osteotomy, combined with or without a Chiari osteotomy from August, 1981 to November, 2002 However, one patient was treated without femoral shortening. The mean age of the patients besides the 2 patients of failure at the time of surgery was 13.1 years (range 8-23), the mean follow up duration was 9.1 years (range 1-22 years). There were 6 cases of left side involvement of DDH, and 5 cases of right side involvement, while the remaining were both sides. One case was male and the others were female, and all hips were dislocated completely. RESULTS: One hip out of 14 patients was not unreduced intraoperatively. One hip showed a redislocation during the follow up period. Eleven patients gained almost the full range of motion of the affected hip except for one patient. Five out of the 12 patients showed a normal gait without limping and pain, and 3showed a slight limping gait but was much improved compared with the preoperative state. Four patients showed a limping gait due to a leg length discrepancy, and the limping gait of one patient was corrected by femoral lengthening. The average Harris hip score among the patients except for 2 cases of failure was 94.6. Nine patients were excellent and 3 patients were good. CONCLUSION: A neglected DDH should be treated positively Because a functionally good hip joint can be obtained after an open reduction of a developmentally dislocated hip, even after the age of 8.