Revision surgery for the stiff total knee arthroplasty.

AIMS: The aim of this study was to examine the results of revision total knee arthroplasty (TKA) undertaken for stiffness in the absence of sepsis or loosening. PATIENTS AND METHODS: We present the results of revision surgery for stiff TKA in 48 cases (35 (72.9%) women and 13 (27.1%) men). The mean age at revision surgery was 65.5 years (42 to 83). All surgeries were performed by a single surgeon. Stiffness was defined as an arc of flexion of < 70° or a flexion contracture of > 15°. The changes in the range of movement (ROM) and the Western Ontario and McMasters Osteoarthritis index scores (WOMAC) were recorded. RESULTS: At a mean follow up of 59.9 months (12 to 272) there was a mean improvement in arc of movement of 45.0°. Mean flexion improved from 54.4° (5° to 100°) to 90° (10° to 125°) (p < 0.05) and the mean flexion contracture decreased from 12.0° (0° to 45°) to 3.5° (0° to 25°) (p < 0.05). The mean WOMAC scores improved for pain, stiffness and function. In patients with extreme stiffness we describe a novel technique, which we have called the 'sloppy' revision. This entails downsizing the polyethylene insert by 4 mm and using a more constrained liner to retain stability. CONCLUSION: To our knowledge, this is the largest series of revision surgeries for stiffness reported in the literature where infection and loosening have been excluded. TAKE HOME MESSAGE: Whilst revision surgery is technically demanding, improvements in ROM and outcome can be achieved, particularly when the revision is within two years of the primary surgery. Cite this article: Bone Joint J 2016;98-B:622-7.

Pregabalin reduces postoperative opioid consumption and pain for 1 week after hospital discharge, but does not affect function at 6 weeks or 3 months after total hip arthroplasty.

BACKGROUND: This study examined whether a perioperative regimen of pregabalin added to celecoxib improved pain scores and functional outcomes postdischarge up to 3 months after total hip arthroplasty (primary outcome) and acute postoperative pain and adverse effects (secondary outcomes). METHODS: One hundred and eighty-four patients were enrolled in a randomized, double-blind, placebo-controlled study. Two hours before receiving a spinal anaesthetic and undergoing surgery, patients received celecoxib 400 mg p.o. and were randomly assigned to receive either pregabalin 150 mg p.o. or placebo p.o. After surgery, patients received pregabalin 75 mg or placebo twice daily in hospital and for 7 days after discharge. Patients also received celecoxib 200 mg every 12 h for 72 h and morphine i.v. patient-controlled analgesia for 24 h. Pain and function were assessed at baseline, 6 weeks, and 3 months after surgery. RESULTS: There was no difference between groups in physical function or incidence and intensity of chronic pain 3 months after total hip arthroplasty. The pregabalin group used less morphine [mean (sd): 39.85 (28.1) mg] than the placebo group [54.01 (31.2) mg] in the first 24 h after surgery (P<0.01). Pain scores were significantly lower in the pregabalin group vs the placebo group on days 1-7 after hospital discharge, and the pregabalin group required less adjunctive opioid medication (Percocet) 1 week after hospital discharge (P<0.05). CONCLUSIONS: Perioperative administration of pregabalin did not improve pain or physical function at 6 weeks or 3 months after total hip arthroplasty. Perioperative administration of pregabalin decreased opioid consumption in hospital and reduced daily pain scores and adjunct opioid consumption for 1 week after discharge.

Perioperative gabapentin reduces 24 h opioid consumption and improves in-hospital rehabilitation but not post-discharge outcomes after total knee arthroplasty with peripheral nerve block.

BACKGROUND: This study was designed to determine whether a 4 day perioperative regimen of gabapentin added to celecoxib improves in-hospital rehabilitation and physical function on postoperative day 4 and 6 weeks and 3 months after total knee arthroplasty (TKA). METHODS: After Research Ethics Board approval and informed consent, 212 patients were enrolled in a randomized, double-blinded, placebo-controlled study. Two hours before surgery, patients received celecoxib 400 mg p.o. and were randomly assigned to receive either gabapentin 600 mg or placebo p.o. Two hours later, patients received femoral, sciatic nerve blocks, and spinal anaesthesia. After operation, patients received gabapentin 200 mg or placebo three times per day (TID) for 4 days. All patients also received celecoxib 200 mg q12 h for 72 h and i.v. patient-controlled analgesia for 24 h. Pain and function were assessed at baseline, during hospitalization, on postoperative day 4 (POD4), and 6 weeks and 3 months after surgery. RESULTS: The gabapentin group used less morphine in the first 24 h after surgery [G=38.3 (29.5 mg), P=48.2 (29.4 mg)] (P<0.0125) and had increased knee range of motion compared with the placebo group in-hospital (P<0.05). There were no differences between groups in favour of the gabapentin group for pain or physical function on POD 4 [95% confidence interval (CI): pain: -1.4, 0.5; function: -6.3, 2.0], 6 weeks (95% CI: pain: 0.1, 1.9; function: -0.2, 6.5) or 3 months (95% CI: pain: -0.2, 1.7; function: -2.2, 4.3) after TKA. CONCLUSIONS: In the context of celecoxib, spinal anaesthesia, femoral and sciatic nerve blocks, a dose of gabapentin 600 mg before operation followed by 4 days of gabapentin 200 mg TID decreased postoperative analgesic requirements and improved knee range of motion after TKA. Gabapentin provided no improvement in pain or physical function on POD4 and 6 weeks or 3 months after surgery.

The importance of perceived helplessness and emotional health in understanding the relationship among pain, function, and satisfaction following revision knee replacement surgery.

OBJECTIVE: Little is known about the relationships among pain, function, psychological variables like perceived helplessness and emotional health, and patient satisfaction in people with revision knee replacement surgery. We hypothesized that pain and function would have a direct association with satisfaction as well as an indirect association through patient perceptions of helplessness and emotional health. DESIGN: This longitudinal study included 145 participants undergoing revision knee replacement surgery. Demographic data and expectation of benefit from surgery were recorded prior to surgery. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Arthritis Helplessness Scale (AHS) and the Mental Component Scale (MCS) of the SF-36 (emotional health) were collected prior to and 2 years post-surgery. Satisfaction was recorded 2 years post-surgery. Regression analyses were conducted to test for mediation effects of helplessness and MCS. RESULTS: Participants were on average 69 years old and 54% were women. Participants were satisfied with the results of the surgery (mean ± standard deviation (SD) = 70.42 ± 31.46). Less pain and functional disability were associated with increased patient satisfaction and, the effect of pain or function was also mediated through helplessness whereby more pain and disability were associated with perceptions of helplessness and helplessness was associated with lower satisfaction. MCS did not mediate the relationship of pain and function with satisfaction. CONCLUSION: Helplessness plays an important role in understanding patient satisfaction. Interventions aimed at improving patient outcome should target not only pain and function but also should address strategies to support people in managing following knee revision surgery to maximize satisfaction with outcome.

Adding gabapentin to a multimodal regimen does not reduce acute pain, opioid consumption or chronic pain after total hip arthroplasty.

BACKGROUND: Gabapentin (GPN) is effective in reducing post-operative pain and opioid consumption, but its effects with regional anesthesia for total hip arthroplasty (THA) are not known. We designed this study to determine whether (1) gabapentin administration reduces pain and opioid use after THA using a multimodal analgesic regimen including spinal anesthesia; (2) pre-operative administration of gabapentin is more effective than post-operative administration. METHODS: After REB approval and informed consent, 126 patients were enrolled in a double-blinded, randomized-controlled study. Patients received acetaminophen 1 g per os (p.o.), celecoxib 400 mg p.o. and dexamethasone 8 mg intravenously, 1-2 h pre-operatively. Patients were randomly assigned to one of three treatment groups (G1: Placebo/Placebo; G2: GPN/Placebo; G3: Placebo/GPN). Patients received gabapentin 600 mg (G2) or placebo (G1 and G3) 2 h before surgery. All patients had spinal anesthesia [15 mg (3cc) of 0.5% hypobaric bupivacaine with 10 microg of fentanyl]. In the post-anesthetic care unit, patients received gabapentin 600 mg (G3) or placebo (G1 and G2). On the ward, patients received acetaminophen 1000 mg p.o. q6h, celecoxib 200 mg p.o. q12h and a morphine PCA device. Patients were interviewed 6 months post-surgery to determine the incidence and severity of chronic post-surgical pain. RESULTS: Mean+/-SD cumulative morphine (mg) consumption (G1=49.4+/-24.8, G2=47.2+/-30.1 and G3=56.1+/-38.2) at 48 h and pain scores at 12, 24, 36 and 48 h post-surgery were not significantly different among the groups [G1 (n=38), G2 (n=38) and G3 (n=38)]. Side effect profiles were similar across groups. Six months after surgery, the number of patients who reported chronic post-surgical pain (G1=10, G2=12 and G3=9) and the severity of the pain (G1=4.2+/-2.9, G2=4.1+/-2.2 and G3=4.9+/-2.2) did not differ significantly among the groups (P>0.05). CONCLUSIONS: A single 600 mg dose of gabapentin given pre-operatively or post-operatively does not reduce morphine consumption or pain scores in hospital or at 6 months after hip arthroplasty within the context of spinal anesthesia and a robust multimodal analgesia regimen.

Functional independence training program: an example of a sub-acute care model for patients following primary joint replacement.

The Orthopaedic and Arthritic Hospital is a specialty institution dedicated to the provision of elective reconstructive orthopaedic surgery and rehabilitation to individuals with musculoskeletal disorders. This facility is the largest volume joint replacement centre in Canada, performing over 1,000 hip and knee replacement/revision procedures annually. In 1995, the hospital established a Functional Independence Training (FIT) program--a seven-day reactivation program for patients following primary joint replacement. The program aims to promote early independence, improve functional level and return patients to normal activity as quickly and cost-effectively as possible. The program has received positive patient feedback and has demonstrated the potential to save the health care system approximately $479,655 annually through the reduction of 1,453 acute and rehabilitation hospital inpatient days, based on the hospital's annual primary joint replacement caseload.

The accuracy of femoral intramedullary guides in total knee arthroplasty.

Of the technical factors important in achieving a successful total knee arthroplasty, limb alignment has been demonstrated to be most influential in determining implant survival. Intramedullary femoral guide systems rely on placement of the intramedullary rod along the anatomic axis of the femur. In this article, the accuracy of the femoral intramedullary guide is investigated using radiographs and a mathematical model. The femoral anatomic axis was drawn on 40 consecutive, preoperative, 3-ft standing radiographs. Using a mathematical model, the potential angular error in the distal femoral cut from aberrant placement of the intramedullary rod was estimated. Calculated values correlated with measured values from plain radiographs and an intramedullary guide template. The anatomic axis was found to exit the distal femur at an average of 6.6 mm medial to the center of the femoral notch. Substantial malalignment error resulted from minor malposition of the intramedullary rod. Most books and diagrams demonstrating the use of intramedullary guides indicate that the entry point is at the center of the femoral notch. These results show that the true entry point is medial to the center of the notch, and rod placement error results in excessive valgus alignment. Preoperative drawing of the anatomic axis on a 3-ft or 18-inch anteroposterior radiograph is recommended. The results both demonstrate the importance of correct use of the guide and heighten cognizance among surgeons performing total knee arthroplasty as to the limitations of the intramedullary guides.

Determinants of 6-12 month postoperative functional status and pain after elective total hip replacement.

OBJECTIVE: The goal of this pilot project was to quantify outcomes of elective total hip replacement through risk adjustment modeling. DESIGN: A retrospective cohort study of patients who underwent elective total hip replacement (THR) during 1991 at the Orthopaedic and Arthritic Hospital in Toronto. STUDY PARTICIPANTS: All patients undergoing elective total hip replacement with a confirmed diagnosis of osteoarthritis were asked to participate in the study; 193 patients agreed. OUTCOME MEASURES: Participants were asked to complete the WOMAC Osteoarthritis Index and the RAND 36-item Health Survey 6 months to 1 year post-operatively. Pre-operative information on pain and functional status was obtained from the patients' medical record. RESULTS: The results indicate that 93% of patients studied reported at least one significant co-morbidity. The mean pre-operative pain score was 7.5 on a 0-10 scale and average change in pain was 4.8. Regression analyses indicate that increased body mass index is associated with lower post-operative functional status and increased post-operative pain. The amount of pain relief the patient was able to obtain pre-operatively using non-surgical interventions was associated with a better outcome.

Appropriateness of primary total hip and knee replacements in regions of Ontario with high and low utilization rates.

OBJECTIVE: To compare the appropriateness of case selection for primary hip and knee replacements between two regions in Ontario: one with a high population-based utilization rate and one with a low rate. DESIGN: Random audit of medical records sampled from hospital discharge abstracts, with subsequent implicit and explicit criteria-based assessments of the appropriateness of surgery. STUDY POPULATION: People aged 60 years or over who underwent elective, single-joint, non-fracture-related, primary hip or knee replacement between Apr. 1, 1992, and Mar. 31, 1993, at one of seven hospitals in a high-rate region (comprising Brant, Huron and Oxford countries) or one of eight hospitals in a low-rate region (comprising the cities of Scarborough and Toronto). INTERVENTIONS: Structured review of hospital medical records, with additional review of information from surgeons and family physicians' office charts if necessary. Three physicians reviewed patient data and rated the preoperative pain level and functional status of patients, with agreement among at least two reviewers. The proportion of inappropriate cases was then assessed according to explicit criteria defined by a multidisciplinary panel using the delphi process. Profiles of each case were also subjected to independent implicit review by two rheumatologists and two orthopedic surgeons. OUTCOME MEASURES: Proportion of joint replacements deemed inappropriate in the high- and low-rate regions according to either the explicit criteria or the implicit review, as well as preoperative pain levels and functional status of patients in the high- and low-rate regions. RESULTS: Hip replacements were more common among patients sampled in the low-rate region than among those in the high-rate region (57.3% v. 39.3%; p < 0.002), although the patients' baseline characteristics, including severity of preoperative pain and dysfunction, were otherwise similar between the regions. Inappropriate surgery, determined by explicit criteria, was equally uncommon in the two regions (6.4% and 6.1%). On implicit review, the two rheumatologists rated fewer cases as appropriate than did the two orthopedic surgeons (63.0% v. 80.0%; p < 0.001); however, the proportion of cases rated as inappropriate by the subspecialists was similar in the high- and low-rate regions (11.4% and 11.0%, respectively, by the rheumatologists, and 6.3% and 10.4%, respectively, by the orthopedic surgeons). CONCLUSIONS: Patients selected for primary hip or knee replacement are similar in the high- and low-rate regions of Ontario. Inappropriate use of this procedure does not account for the high rate of surgery in some areas. Further studies will be required to determine which other factors account for the regional variations in the utilization rates and whether there is underservicing in low-rate areas.