The Posterolateral Approach for Calcaneal Fractures.

BACKGROUND: Conventionally, the extended lateral approach (ELA) served as the standard extensile approach for intraarticular calcaneal fracture fixation. However, this approach has a high rate of wound complications. The purpose of this study was to describe an alternative approach, the posteriorlateral approach (PLA) and compare it to the ELA regarding soft tissue complications and functional outcome. MATERIALS AND METHODS: 32 patients operated through PLA and 66 patients treated through ELA were included in this retrospective study. Major and minor soft tissue complications up to 3 months postoperatively were recorded. Eighteen patients of the PLA group and 32 patients of the ELA group were available for 1-year functional outcome assessment with the American Foot and Ankle Score (AOFAS) score. RESULTS: The PLA group had no major complications requiring surgical intervention. Six patients (19%) had minor wound complications. The ELA group had 8 (12%) major complications and 9 (14%) minor complications. There were no significant differences in AOFAS scores at 1-year followup. PLA is a safe and efficient approach for open reduction and internal fixation of displaced intraarticular calcaneal fractures. CONCLUSION: In selected cases when fracture comminution and displacement may not be adequately treated through a less invasive approach, it is a good alternative with less concern about wound complications as in ELA.

Partial lateral patellar facetectomy as an alternative to lateral release in Total Knee Arthroplasty (TKA).

This study presents the selective use of partial patellar lateral facetectomy for maltracking during primary TKA, as an alternative to lateral release. Twenty three partial facetectomies were performed out of 191 TKAs (12%). Balanced tracking was achieved in 22 knees. At follow-up 2 patients had persistent anterior knee pain. Mean Knee Society score (KSS) was 94 and mean functional KSS was 86. Mean patellar score was 28. Patellar tilt angles were within 2 degrees in all but one knee. Patellar translation was within 2 mm in all cases. No complications were recorded. A control group of 46 matched patients had similar functional and radiographic results. If tracking is not satisfactory at the conclusion of TKA, our method of choice would be partial lateral facetectomy.

Age- and sex-dependent hormonal modulation of the expression of vitamin D receptor and 25-hydroxyvitamin D 1α hydroxylase in human bone cells.

BACKGROUND: Human cultured osteoblasts from pre-Ob, post-Ob or m-Ob express different mRNAs and respond to different hormones. AIMS: To test expression and hormonal modulation of VDR and 1OHase and 1,25D production in hObs. METHODS: hObs obtained from bone explants were prepared, treated and analyzed as before. RESULTS: (i) VDR and 1OHase were expressed in all hObs. (ii) 1,25D was produced similarly. (iii) Treatment with E2, DPN (ER agonist), but not PPT (ER agonist) increased VDR. (iv) These hormones increased 1OHase. (v) Vitamin D analog JKF and PTH 1-84 increased similarly mRNAs. (vi) Treatment with E2, DPN and PPT increased 1,25D. (vii) JKF and PTH increased similarly 1,25D. (viii) DNA synthesis and CK were stimulated by all hormones in hObs. CONCLUSIONS: Hormonal modulation of VDR and 1OHase and 1,25D production is important for bone physiology but their correlation, activity and bone physiology is not yet clear.

Precise technique for simple and accurate pip arthrodesis using a blunt KW technique.

Proximal interphalangeal joint (PIP) arthrodesis is a very common procedure in the practice of foot and ankle surgeons. The standard technique recommends using a Kirschner wire (KW) with double sharp ends. Using this technique there are some complication that can be eliminated by small modification. The technique of proximal interphalangeal joint arthrodesis using a simple blunt KW on one side with an accurate placement and avoidance of metatarsophalangeal joint (MTPJ) penetration without the need for fluoroscopy is described. This technique is simple, reproducible, very economical and avoiding most of the complications attributed to the KW.

Pseudallescheria boydii infection of a prosthetic hip joint--an uncommon infection in a rare location.

Pseudallescheria boydii infection of the hip joint was diagnosed 2.5 years after implantation of a prosthetic joint in a woman with rheumatoid arthritis. Cure was achieved with a 10-month course of voriconazole coupled with removal of the prosthesis and repeat surgical debridement. Pseudallescheria boydii is an environmental mold that can cause osteoarticular infection, most often not only after local trauma but also after local injections and surgical procedures. Hip involvement was rarely reported, and this is the first description of a prosthetic joint infection with Scedosporium sp.

Sex specific response of cultured human bone cells to ERα and ERß specific agonists by modulation of cell proliferation and creatine kinase specific activity.

We have previously reported that human cultured bone cells (hObs) respond to estradiol-17ß (E2) by stimulating DNA synthesis, creatine kinase BB specific activity (CK) and other parameters sex-specifically. We now investigate the sex specificity of the response of these hObs to estrogen receptor (ER) α and ERß specific agonists. Real time PCR revealed that all cells express mRNA for both ERs. ERα mRNA but not ERß mRNA was stimulated by all estrogenic compounds in both pre- and post-menopausal hObs with no effect in male hObs. Cells treated with E2, 2,3-bis (4-hydroxyphenyl)-propionitrile (DPN; ERß specific agonist) and 4,4',4″-[4-propyl-(1H)-pyrazol-1,3,5-triyl] tris-phenol (PPT; ERα specific agonist) showed increased DNA synthesis and CK in all female but not male hObs. Raloxifene (Ral), a specific ERα antagonist, inhibited the stimulation of DNA synthesis and CK by E2 or PPT, but not by DPN. DPN and PPT like E2 modulated the expression of both 12 and 15 lipooxygenase (LO) mRNA in both female but not male hObs. 12 and 15 HETE production was modulated only by DPN and PPT in these cells. The LO inhibitor baicaleine inhibited only E2 and PPT but not DPN effects in both female hObs. In conclusion, we provide herein evidence for the separation of age- and sex-dependent mediation via both ERα and ERß pathways in the effects of estrogens on hObs, with a yet unknown mechanism.

Serum transforming growth factor beta-1 post hip fracture repair in elderly patients.

BACKGROUND: To determine the kinetics of serum transforming growth factor beta-1 (TGF-ß1) in aged hip fracture patients during a month post-op. and determine its relationship to complications and cognitive status. METHODS: Forty-one elderly patients were prospectively followed. Serum TGF-ß1 was obtained during the first 10h post-fracture (baseline) and pre-surgery, 48-60 h post-op., 7 and 30 days post-op. RESULTS: Mean age was 81.8±7.7, range 68-97 years. A significant increase in serum TGF-ß1 (from baseline) was observed on the seventh day post-op., lasting for at least 1 month (p = 0.004). Sixteen patients experienced post-op. complications. Serum TGF-ß1 of patients with complications was significantly higher compared to patients without complications (p = 0.039). More complications were found in impaired mental status (IMS) patients (9/12) compared to cognitively normal patients (10/29), (p = 0.037). However, no differences were found in serum TGF-ß1 between IMS and normal patients, nor was a correlation found between age and TGF-ß1 production. No differences were found between genders. CONCLUSIONS: There is a distinct increase in serum TGF-ß1, a week post hip fracture repair, lasting for at least a month, which is significantly higher in patients with post-op. complications. TGF-ß1 seems to be essential to the healing process post hip fracture repair; still its clinical applications have as yet to be determined.

Achilles tendon rupture and our experience with the Achillon device.

BACKGROUND: Open repair of the Achilles tendon is still the gold standard for treating rupture. This technique has the disadvantages of a long and problematic operative scar and thickly scarred Achilles tendon. To improve the surgical outcome minimally invasive techniques have been developed. OBJECTIVES: To analyze our results of Achilles tendon repair using the Achillon device and compare them with published studies. METHODS: We performed surgical repair of the Achilles tendon in 28 patients during a 4 year period (2004-2008): 14 patients were treated with the Achillon device, 12 with the open suture technique and 2 with the percutaneous method. Fourteen patients were available for follow-up: 9 patients with the Achillon device, 3 patients with open suturing and 2 patients with the percutaneous technique. Follow-up ranged from 1 to 4 years. RESULTS: The average score of the AOFAS Ankle-Hindfoot Scale for the group treated with the Achillon device was 95.6 points (range 84-100) and for the group treated with the open method, 90 points (range 84-98). The length of the scar in patients operated with a minimally invasive technique was 3.81 cm (range 1-6 cm) as compared to 9.16 cm (range 8-10.5 cm) with the open suture. CONCLUSIONS: This is the first review on this procedure in Israel. Excellent functional results were achieved with this technique. Our outcomes were similar to those of two other studies.

Magnetic isolation of particles suspended in synovial fluid for diagnostics of natural joint chondropathies.

Millions of people are stricken with the degenerative joint disease known as osteoarthritis. Osteoarthritis is associated with biochemical and mechanical processes, and is characterized by loss of articular cartilage and hypertrophy of bone. As cartilage and bone particles are released into the synovial fluid, a variety of biomarkers have been suggested for the analysis of this fluid. Here we have developed a method for isolating bone and cartilage wear particles suspended in the synovial fluid of the hip, knee and ankle joints of humans, based on specific magnetization of collagens I and II. Bio-ferrography is used to capture the particles on glass slides, allowing microscopic, chemical and statistical analyses. The relations between the level of the disease and the number, dimensions, shape and chemical composition of the particles were established. The method, which was found to be sensitive and reliable, can easily be extended to other applications, such as diagnosis of cancer and infectious diseases, determination of the efficacy of drugs or optimization of implants.

Measuring bone speed of sound in patients with hip fractures: a comparison with pathological examination.

The aim of this multicenter prospective study is to compare and find a relation between bone strength evaluated by an ultrasound examination (bone speed of sound) and pathological quantitative bone mass measurements, in patients requiring hip replacement due to femoral neck fractures. The study included 93 patients who underwent a bone ultrasound examination to assess bone strength, as well as a pathological quantitative bone mass evaluation of the excised femoral head. Statistically significant correlations were found between the ultrasound results performed at three different sites, between the patient's age and the ultrasound examination results, and between the patient's age and the pathological examination results of the bone strength. We found no statistically significant correlation between the ultrasound examination results in any of the three locations and the pathological results. Therefore, conclusions cannot be made with respect to the efficacy and reliability of the ultrasound examination in predicting bone strength. However, the study can be used as a learning tool for future studies, by trying to overcome the obstacles found in the present study that have most likely lead to the negative results.

The use of 99mTc-recombinant human annexin V imaging for differential diagnosis of aseptic loosening and low-grade infection in hip and knee prostheses.

UNLABELLED: The aim of this study was to assess the pattern of annexin V uptake in hip and knee prostheses suspected of being infected. METHODS: A total of 7 patients undergoing revision surgery for hip or knee prostheses were studied; 5 patients had total hip replacements, and 2 had total knee replacements. Infection was confirmed by pathology, culture results, laboratory evaluation, and clinical follow-up. All patients also underwent a bone scan before surgery. RESULTS: Annexin V scan findings were positive in 5 patients and negative in 2. Annexin V uptake was either focal (n = 4) or linear (n = 1). There were 4 true-positive, 2 true-negative, 1 false-positive, and no false-negative annexin V studies. Annexin V uptake was either more extensive or less extensive than, and usually was incongruent with, (99m)Tc-methylene diphosphonate uptake. CONCLUSION: Our findings suggest that annexin V imaging shows greater uptake with infection than with aseptic loosening and has a high negative predictive value for prosthetic infection.

Enhanced osseointegration of grit-blasted, NaOH-treated and electrochemically hydroxyapatite-coated Ti-6Al-4V implants in rabbits.

Osseointegration, in terms of the bone apposition ratio (BAR) and the new bone area (NBA), was measured by backscattered electron imaging. The results were compared for four implant types: grit-blasted and NaOH-treated Ti-6Al-4V (Uncoated-NaOH), electrodeposited with hydroxyapatite without alkali treatment (ED-HAp), electrodeposited with hydroxyapatite after alkali treatment (NaOH-ED-HAp), and plasma sprayed with hydroxyapatite (PS-HAp). No heat treatment was done after soaking in NaOH. The implants were press fitted into the intramedullary canal of mature New Zealand white rabbits and analyzed, both at the diaphyseal and at the metaphyseal zones, either 1week or 12weeks after surgery. NaOH-ED-HAp already exhibited a higher BAR value than the ED-HAp at 1week, and was as good as the commercial PS-HAp at 12weeks. The NBA value for NaOH-ED-HAp at 12weeks was the highest. The higher content of octacalcium phosphate in NaOH-ED-HAp, as evident from the X-ray photoelectron spectroscopy analysis of the oxygen shake-up peaks, and the associated increase in the solubility of this coating in vivo are considered responsible for the enhanced osseointegration. Taking into account also the reduced occurrence of delamination and the inherent advantages of the electrodeposition process, electrodeposition of HAp following soaking in NaOH may become an attractive alternative for the traditional plasma-sprayed process for coating of orthopedic and dental implants.

Lipoxygenase metabolites are mediators of PTH-dependent human osteoblast growth.

PTH-induced osteoblast proliferation may contribute to its anabolic effects in bone. Since PTH-dependent osteoblast-like cell (Ob) growth is mediated via protein kinase C (PKC) and MAP kinase-kinase (MEK) and since lipoxygenase (LO) products activate PKC in a number of cell types, we assessed the expression of LO pathways in primary human cultured Ob. Ob from pre- or post-menopausal women were cultured and were treated with PTH and assayed for the expression of 12-LO and both type I and type II 15-LO mRNA and for the release their enzymatic products, 12- and 15-hydroxyeicosatetraenoic acid (HETE). Cells were also treated with PTH for stimulation DNA synthesis. First, Ob express platelet type- 12-LO and both type I and type II 15-LO mRNA and release their enzymatic products, 12- and 15-hydroxyeicosatetraenoic acid (HETE). Second, in female Ob, PTH induced a rapid increase in 12-HETE (50 fold increase) and 15-HETE (80 fold increase) and increased the expression of 12-LO mRNA but not of the two isoforms of 15-LO. PTH as well as 12 and 15-HETE stimulated DNA synthesis in Ob. The LO inhibitor baicalein inhibited PTH-stimulated DNA synthesis, which was reversed in the presence of either 12- or 15-HETE. A PKC inhibitor (bisindolylmaleimide I) as well as a MEK inhibitor (PD 98059) completely inhibited the stimulation of DNA synthesis by PTH, 12-HETE and the combination of PTH and 12-HETE. In contrast, 15-HETE-induced DNA synthesis was not abolished by these inhibitors. Further, 15-HETE partially restored the stimulatory effect of PTH on DNA synthesis in cells treated with PKC or MEK inhibitors. Finally, PTH- induced ERK1/2 phosphorylation, was blocked by a MEK inhibitor. These results demonstrate a novel mechanism of PTH-induced human bone cell proliferation operating through LO enzymes.

25 hydroxy-vitamin D(3)-1alpha hydroxylase expression and activity in cultured human osteoblasts and their modulation by parathyroid hormone, estrogenic compounds and dihydrotestosterone.

Human osteoblasts (hOB) produce and respond to 1,25(OH)(2)D(3) (1,25D), suggesting an autocrine/paracrine system. We therefore examined hormonal modulation of the expression and activity of 25 hydroxy-vitamin D(3)-1alpha hydroxylase (1-Ohase) in hOB. Cells from pre- and post-menopausal women or men, were treated with estrogenic compounds and 1-OHase expression and activity were measured. 1-OHase mRNA expression was highest in pre-menopausal women hOB and was increased by all hormones tested. In post-menopausal hOB all hormones except biochainin A (BA) and genistein (G) increased 1-OHase mRNA expressions to less extent. In male-derived hOB only dihydrotestosterone (DHT) and carboxy BA (cBA) increased 1-OHase mRNA expression. 1,25D production from 25(OH)D(3) had a K(m) of approximately 769-400 ng/ml (1.92-1.07 microM) and V(max) of 31.3-17.4 ng/ml (0.078-0.044 microM/60 min/5 x 10(6)cells) respectively, and was increased by all hormones except raloxifene (Ral) with higher stimulation in pre- than in post-menopausal cells. Only BA was almost five times more potent in pre- rather than post-menopausal hOBs. In male hOB only DHT and cBA increased 1,25D production whereas estradiol-17beta (E(2)) had no effect and BA decreased it. These results provide evidence for the expression of 1-OHase mRNA and production of 1,25D in hOBs, which are age and sex dependent and are hormonally modulated. The role of this local autocrine/paracrine 1,25D system in bone physiology deserves further investigation.

Cytokines and C-reactive protein production in hip-fracture-operated elderly patients.

BACKGROUND: The study aim was to determine the kinetics of serum pro- and anti-inflammatory cytokines and C-reactive protein (CRP) in hip-fracture patients over a month postfracture, and their relationship to postoperative (postop) complications and cognitive level. METHODS: Forty-one elderly hip-fracture patients were prospectively followed. Serum was obtained during the first 10 hours postfracture and presurgery, 48-60 hours postop, 7 and 30 days postop, measuring CRP, interleukin-1beta (IL-1beta), IL-6, IL-8, tumor necrosis factor-alpha (TNF-alpha), IL-10, and IL-1 receptor antagonist (IL-1RA). RESULTS: A significant increase was found postop for CRP, IL-6, TNF-alpha, IL-1RA (p <.001), IL-10 (p <.002), and IL-8 (p =.05). CRP kinetics curves were higher in patients with complications as a group, and in those suffering from infections, delirium, and cardiovascular complications (p <.05). IL-6 increase in patients with complications approached significance. Additional complications appeared in patients with impaired mental status (IMS) versus cognitively normal patients (p =.037). Higher kinetics curves in the IMS patients were found for CRP and IL-6 (p <.05). Analyzing the interaction effect of complications and IMS on CRP and cytokines production demonstrated that the increase in CRP was independently related to complications and IMS. IL-6, IL-8, and IL-10 were higher in IMS patients but not in patients with complications without IMS (p <.05). CONCLUSIONS: Serum CRP and cytokines increased drastically in postop hip-fracture elderly patients. Only CRP significantly and independently increased in IMS patients and in patients with complications, whereas cytokines significantly increased only in IMS patients. This study raises questions about possible effects that cytokine generation, after hip-fracture repair, might have on cognition and complications.

DT56a (Femarelle): a natural selective estrogen receptor modulator (SERM).

A selective estrogen receptor modulator (SERM) is defined as a substance with dissimilar effects on different tissues: agonist in some and antagonists in others. The natural compound DT56a (Femarelle) was shown to activate estrogen receptors in human cultured female derived osteoblasts. It was also shown to relieve menopausal symptoms and to increase bone mineral density with no effect on sex steroid hormone levels and on the endometrial thickness. DT56a, similarly to estradiol-17beta (E2), stimulated the specific activity of creatine kinase (CK) in skeletal and vascular tissues of female rats, as a marker of estrogen receptor (ER) activation. However, in the uterus, CK was activated only by E2 but not by DT56a. In order to prove that DT56a is a SERM, we examined the mutual interaction between DT56a and E2, at supra physiological doses, in different tissues in both intact and ovariectomized female rats, as well as in human cultured vascular and bone cells. Administration of DT56a or E2 stimulated CK in all tissues tested, but when given simultaneously, in intact immature female rats, DT56a completely abolished E2 stimulation of CK in all organs except in the diaphyseal bone where the inhibition was partial. In ovariectomized female rats, DT56a abolished E2's stimulation of CK in diaphyseal bone, thymus, uterus and pituitary but caused a partial inhibition in aorta, left ventricle and epiphyseal cartilage. In human bone cells E2 stimulation of CK, of alkaline phosphatase (AP) activity and of DNA synthesis was completely abolished by DT56a in post-menopausal cells and partially inhibited in pre-menopausal cells. In human vascular cells, inhibition of DNA synthesis by E2 was completely abolished by DT56a and E2-induced CK was partially inhibited by DT56a. The results support the finding that DT56a is a SERM; it stimulated different parameters similar to E2, but when given simultaneously, at supra physiological doses, inhibited these E2's effects. Further investigations regarding intra and extra cellular mechanism of action of DT56a are currently performed.

The importance of blood sampling site for determination of hemoglobin and biochemistry values in major abdominal and orthopedic surgery.

STUDY OBJECTIVE: To determine whether sampling of blood from different sites influences laboratory results. DESIGN: Prospective, double-blind study. SETTING: University-affiliated hospital in Israel. PATIENTS: 100 ASA physical status I, II, and III patients undergoing major orthopedic or colon surgery (total hip and revision of total hip replacement, colon resection, or radical cystectomy). MEASUREMENTS: Blood was sampled simultaneously for hemoglobin, electrolytes, glucose, pH, blood gases, and lactate from three sampling sites (peripheral vein, central vein, and radial artery) at 5 time frames (after induction of anesthesia [baseline], one hr after induction of anesthesia, at the end of surgery, after one hr in the recovery room, and 4 hrs after surgery). At the same time points, recorded rectal temperature, mean arterial pressure, heart rate, and central venous pressure were recorded. Anesthesia, monitoring, and dwell volumes before sampling were standardized. MAIN RESULTS: There were no significant differences between the results of hemoglobin, electrolytes, glucose, pH, and blood gases obtained from different sampling sites and at different time frames. Lactate level (mmol/L) was higher in peripheral venous blood than it was in either the central vein or radial artery (<0.05), and higher in central venous blood compared with arterial blood (P < 0.05; 2.04 +/- 1.16, 1.74 +/- 0.78, and 1.54 +/- 0.68, respectively). CONCLUSION: Under stable hemodynamics and in the absence of hypothermia, serum lactate level was higher in peripheral venous blood than it was in the central vein or radial artery.

Phialemonium curvatum arthritis of the knee following intra-articular injection of a corticosteroid.

Phialemonium curvatum arthritis of the knee developed in a diabetic man following intra-articular injection of a corticosteroid. Cure was achieved with a 6-week course of intravenous amphotericin B deoxycholate. P.curvatum is commonly found in the environment and is often considered a contaminant; yet, its pathogenic potential should be seriously considered in selected patients.

Responsiveness to estradiol-17beta and to phytoestrogens in primary human osteoblasts is modulated differentially by high glucose concentration.

We have reported previously, that female-derived bone cells responded to 17beta-estradiol (E(2)) and to raloxifene (Ral), whereas male-derived cells responded only to dihydrotestosterone (DHT) when the stimulation of creatine kinase specific activity (CK), which is a marker for hormone responsiveness, was measured. In cells derived from pre-menopausal women, E(2), G, D and Ral stimulated CK to higher extent compared to post-menopausal bone cells, whereas quecertin (Qu), carboxy-biochainin A (cBA) and carboxy-genistein (cG) stimulated CK in both age groups similarly, and biochainin A (BA) stimulated post-menopausal cells to a bit higher extent than pre-menopausal cells. Since the skeletal protective effects of estrogens are not discernable in diabetic women, we tested in this study, the effects of high glucose concentration in the growth medium, on the effects of estrogenic compounds on CK in human-derived bone cells (hObs). Female-derived hObs were grown either in normal (4.5 g/l; 22 mM, NG) or high glucose (9.0 g/l; 44 mM, HG) for 7 days. HG increased constitutive CK, but attenuated E(2)- and DHT-induced CK in female or male hObs, respectively. HG also inhibited genistein (G) and daidzein (D) stimulated CK in female hObs, but not the effects of biochainin A (BA), quecertin (Qu) or Ral. Intracellular, mainly nuclear binding of (3)[H]E(2) was characteristic of the different phytoestrogens in female hObs, was abolished by HG. Membranal binding of Eu-Ov-E(2), was displaced only by E(2)-Ov, ICI, cG-Ov or cD-Ov but decreased total binding of Eu-Ov-E(2) in both age groups and completely abolished the competition with E(2)-Ov or ICI in both age groups, but the competition with cD-Ov and cG-Ov was decreased only slightly but not statistically significant. HG also abolished Eu-BSA-T, which bound similarly male-derived hObs. All hObs expressed mRNA for ERalpha and ERbeta with higher abundance of ERalpha. HG increased mRNA for both ERs in female-derived hObs, but decreased mRNA for both ERs in male-derived hObs. Hence, human bone cells, which express specific nuclear and membranal binding sites for estrogenic compounds, are modulated by HG, leading to altered hormonal responsiveness, which might block important effects of estrogenic compounds, contributing probably to their decreased skeletal preserving properties under hyperglycemia.

Blood rheology in PCA and PCEA after total knee arthroplasty.

The rheological events in 2 groups of patients undergoing total knee arthroplasty were compared--15 patients were given general anesthesia and controlled their postoperative pain applying intravenous patient-controlled analgesia; 17 individuals received combined spinal-epidural anesthesia and controlled their postoperative pain by patient-controlled epidural analgesia (PCEA). Twenty-four and 48 hours after surgery, the patient-controlled analgesia group showed a significant increase in whole-blood viscosity at the 3 shear rates (P < .01), as well as in relative viscosity at both periods (P < .001 and .01, respectively). Similar findings were observed for red blood cell aggregation (P < .001) and fibrinogen level (P < .001). These values were less expressed in the PCEA group, particularly 48 hours after surgery (P < .01), and the patients showed lower scores on the visual analog pain scale. The better results observed in the PCEA group favor the application of epidural anesthesia and PCEA analgesia in patients undergoing total knee arthroplasty.