Harris Hip Score and SF-36 following metal-on-metal total hip arthroplasty and hip resurfacing - a randomized controlled trial with 5-years follow up including 75 patients.

BACKGROUND: The metal-on-metal large-diameter-head (MoM-LDH) hip replacements increased in popularity during the start of the twenty-first century. Subsequently reports raised concerns regarding adverse reactions due to elevated chromium (Cr) and cobalt (Co) concentrations as well as high rates of other complications and revisions. The purpose was to compare Harris Hip Score and SF-36 at 5-years follow up following MoM-LDH total hip arthroplasty (MoM-LDH-THA) or MoM hip resurfacing (MoM-HR). METHODS: The study was conducted between November 2006 to January 2012 in a tertiary health care center in Denmark. Patients with primary or secondary osteoarthritis were randomly assigned to receive a Magnum (MoM-LDH-THA) or a Recap (MoM-HR) prosthesis. Randomization was computer generated and allocation was concealed in an opaque envelope. Neither patients nor care provider were blinded. Primary outcome was Harris Hip Score at 5-years follow up. RESULTS: Seventy-five were included and allocated to the MoM-LDH-THA (n = 39) and MoM-HR (n = 36) group. The study was prematurely stopped due to numerous reports of adverse events in patients with MoM hip replacements. Thirty-three in the MoM-LDH-THA and 25 in the MoM-HR group were available for primary outcome analysis. Median Harris Hip Score was 100 (IQR: 98-100) for MoM-LDH-THA and 100 (IQR: 93-100) for MoM-HR (p = 0.486). SF-36 score was high in both groups with no significant difference between groups. CONCLUSION: Harris Hip Score and SF-36 score was excellent in both groups with no significant difference at 5-years follow up. Our findings suggest that there is no clinical important difference between the two prostheses implanted 5 years after implantation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04585022 , Registered 23 September 2020 - Retrospectively registered. This study was not prospectively registered in a clinical trial database since it was not an entirely implemented standard procedure in the international orthopedic society when the study was planned.

Introduction of a New Treatment Algorithm Reduces the Number of Periprosthetic Femoral Fractures After Primary Total Hip Arthroplasty in Elderly Females.

BACKGROUND: Increasing global usage of cementless prostheses in total hip arthroplasty (THA) presents a challenge, especially for elderly patients. To reduce the risk of early periprosthetic femoral fractures (PFFs), a new treatment algorithm for females older than 60 years undergoing primary THA was introduced. The aim of this study was to determine the impact of the new treatment algorithm on the early risk of perioperative and postoperative PFFs and guideline compliance. METHODS: A total of 2405 consecutive THAs that underwent primary unilateral THA at our institution were retrospectively identified in the period January 1, 2013-December 31, 2018. A new treatment algorithm was introduced on April 1, 2017 with female patients aged older than 60 years intended to receive cemented femoral components. Before this, all patients were scheduled to receive cementless femoral components. Demographic data, number of perioperative and postoperative PFFs, and surgical compliance were recorded, analyzed, and intergroup differences compared. RESULTS: The utilization of cemented components in female patients older than 60 years increased from 12.3% (n = 102) to 82.5% (n = 264). In females older than 60 years, a significant reduction in the risk in early postoperative and intraoperative PFF after introduction of the new treatment algorithm was seen (4.57% vs 1.25%; P = .007 and 2.29% vs 0.31%; P = .02, respectively). Overall risk for postoperative and intraoperative fractures combined was also reduced in the entire cohort (4.1% vs 2.0%; P = .01). CONCLUSION: Use of cemented fixation of the femoral component in female patients older than 60 years significantly reduces the number of PFFs. Our findings support use of cemented femoral fixation in elderly female patients.

Are There Differences in Micromotion on Radiostereometric Analysis Between Bicruciate and Cruciate-retaining Designs in TKA? A Randomized Controlled Trial.

BACKGROUND: Bicruciate-retaining TKA has been proposed to improve clinical outcomes by maintaining intrinsic ACL function. However, because the unique design of the bicruciate-retaining tibial component precludes a tibial stem, fixation may be compromised. A radiostereometric analysis permits an evaluation of early migration of tibial components in this setting, but to our knowledge, no such analysis has been performed. QUESTIONS/PURPOSES: We performed a randomized controlled trial using a radiostereometric analysis and asked, at 2 years: (1) Is there a difference in tibial implant migration between the bicruciate-retaining and cruciate-retaining TKA designs? In a secondary analysis, we asked: (2) Is there a difference in patient-reported outcomes (Oxford Knee Score [OKS] and Forgotten Joint Score [FJS] between the bicruciate-retaining and cruciate-retaining TKA designs? (3) What is the frequency of reoperations and revisions for the bicruciate-retaining and cruciate-retaining TKA designs? METHODS: This parallel-group trial (ClinicalTrials.gov: NCT01966848) randomized 50 patients with an intact ACL who were eligible to undergo TKA to receive either a bicruciate-retaining or cruciate-retaining TKA. Patients were blinded to treatment allocation. The primary outcome was the maximum total point motion (MTPM) of the tibial component measured with model-based radiostereometric analysis (RSA) at 2 years postoperatively. The MTPM is a translation vector defined as the point in the RSA model that has the greatest combined translation in x-, y- and z-directions. A 1-year postoperative mean MTPM value of 1.6 mm has been suggested as a threshold for unacceptable increased risk of aseptic loosening after both 5 and 10 years. The repeatability of the MTPM was found to be 0.26 mm in our study. Patient-reported outcome measures were assessed preoperatively and at 2 years postoperatively with the OKS (scale of 0-48, worst-best) and FJS (scale of 0-100, worst-best). Baseline characteristics did not differ between groups. At 2 years postoperatively, RSA images were available for 22 patients who underwent bicruciate-retaining and 23 patients who underwent cruciate-retaining TKA, while patient-reported outcome measures were available for 24 patients in each group. The study was powered to detect a 0.2-mm difference in MTPM between groups (SD = 0.2, significance level = 5%, power = 80%). RESULTS: With the numbers available, we found no difference in MTPM between the bicruciate-retaining and cruciate-retaining groups. The median (interquartile range [IQR]) MTPM was 0.52 mm (0.35 to 1.02) and 0.42 mm (0.34 to 0.70) in the bicruciate-retaining and cruciate-retaining groups, respectively (p = 0.63). There was no difference in the magnitude of improvement in the OKS from preoperatively to 2 years postoperative between the groups (median delta [IQR] for bicruciate-retaining 18 [14 to 23] versus cruciate-retaining 18 [15 to 21], difference of medians 0; p = 0.96). Likewise, there was no difference in the magnitude of improvement in the FJS score from preoperatively to 2 years postoperative between the groups (mean ± SD for bicruciate-retaining 46 ± 32 versus cruciate-retaining 48 ± 16, mean difference, 2; p = 0.80). Three patients in the bicruciate-retaining group underwent arthroscopically assisted manipulation at 3 to 4 months postoperatively, and one patient in the bicruciate-retaining group sustained a tibial island fracture during primary surgery and underwent a revision procedure after 6 months. There were no reoperations or revisions in the cruciate-retaining group. CONCLUSIONS: With the numbers available, we found no differences between the bicruciate-retaining and the cruciate-retaining implants in terms of stable fixation on RSA or patient-reported outcome measure scores at 2 years, and must therefore recommend against the routine clinical use of the bicruciate-retaining device. The complications we observed with the bicruciate-retaining device suggest it has an associated learning curve and the associated risks of novelty with no demonstrable benefit to the patient; it is also likely to be more expensive in most centers. Continued research on this implant should only be performed in the context of controlled trials. LEVEL OF EVIDENCE: Level II, therapeutic study.

Cementless One-Stage Revision in Chronic Periprosthetic Hip Joint Infection. Ninety-One Percent Infection Free Survival in 56 Patients at Minimum 2-Year Follow-Up.

BACKGROUND: Cementless 1-stage revision in chronic periprosthetic hip joint infections is limited evaluated. The purpose of this study was to evaluate a specific treatment protocol in this patient group. METHODS: The study was performed as a multicenter, proof-of-concept, observational study with prospective data collection. Patients were treated with a cementless 1-stage revision according to the CORIHA protocol between 2009 and 2014. Fifty-six patients, McPherson type III-A/B-1/2, were enrolled with a mean follow-up time from the CORIHA procedure of 4 years (minimum of 2 years). The primary outcome was re-revision performed due to infection and was evaluated by competing risk analysis, with death and aseptic revision as competing events. All-cause mortality was evaluated by Kaplan-Meier survival analysis. Oxford Hip Score (OHS) was used as disease-specific patient-reported outcome measure. RESULTS: The cumulative incidence of re-revision due to infection was 8.9% (confidence interval [CI] 3.2%-18.1%). The 1-year and 5-year survival incidence was 96% (CI 86%-99%) and 89% (CI 75%-95%). OHS at baseline was 19.9 (CI 17.3-22.6) and at 24-month follow-up 35.1 (CI 31.7-38.5). The mean change in OHS from baseline to 24-month follow-up was 11.8 points (CI 7.3; 16.3). Three patients had aseptic revision performed: two suffered periprosthetic fractures and one had stem subsidence. Failure analysis of the 5 reinfections did not detect a clear pattern as to the cause of failure. CONCLUSION: We found that cementless 1-stage revision in chronic periprosthetic hip joint infections has low reinfection rates in selected patients and may be applicable as a first-line treatment.

Antibody-Mediated Neutralization of uPA Proteolytic Function Reduces Disease Progression in Mouse Arthritis Models.

Genetic absence of the urokinase-type plasminogen activator (uPA) reduces arthritis progression in the collagen-induced arthritis (CIA) mouse model to an extent just shy of disease abrogation, but this remarkable observation has not been translated into therapeutic intervention. Our aim was to test the potential in mice of an Ab that blocks the proteolytic capacity of uPA in the CIA model and the delayed-type hypersensitivity arthritis model. A second aim was to determine the cellular origins of uPA and the uPA receptor (uPAR) in joint tissue from patients with rheumatoid arthritis. A mAb that neutralizes mouse uPA significantly reduced arthritis progression in the CIA and delayed-type hypersensitivity arthritis models. In the CIA model, the impact of anti-uPA treatment was on par with the effect of blocking TNF-α by etanercept. A pharmacokinetics evaluation of the therapeutic Ab revealed target-mediated drug disposition consistent with a high turnover of endogenous uPA. The cellular expression patterns of uPA and uPAR were characterized by double immunofluorescence in the inflamed synovium from patients with rheumatoid arthritis and compared with synovium from healthy donors. The arthritic synovium showed expression of uPA and uPAR in neutrophils, macrophages, and a fraction of endothelial cells, whereas there was little or no expression in synovium from healthy donors. The data from animal models and human material provide preclinical proof-of-principle that validates uPA as a novel therapeutic target in rheumatic diseases.

Chronic loss of inhibitor-1 diminishes cardiac RyR2 phosphorylation despite exaggerated CaMKII activity.

Inhibitor-1 (I-1) modulates protein phosphatase 1 (PP1) activity and thereby counteracts the phosphorylation by kinases. I-1 is downregulated and deactivated in failing hearts, but whether its role is beneficial or detrimental remains controversial, and opposing therapeutic strategies have been proposed. Overactivity of Ca2+/calmodulin-dependent protein kinase II (CaMKII) with hyperphosphorylation of ryanodine receptors (RyR2) at the CaMKII-site is recognized to be central for heart failure and arrhythmias. Using an I-1-deficient mouse line as well as transfected cell lines, we investigated the effects of acute and chronic modulation of I-1 on CaMKII activity and RyR2 phosphorylation. We demonstrate that I-1 acutely modulates CaMKII by regulating PP1 activity. However, while ablation of I-1 should thus limit CaMKII-activation, we unexpectedly found exaggerated CaMKII-activation under ß-adrenergic stress upon chronic loss of I-1 in knockout mice. We unraveled that this is due to chronic upregulation of the exchange protein activated by cAMP (EPAC) leading to augmented CaMKII activation, and using computational modeling validated that an increase in EPAC expression can indeed explain our experimental findings. Interestingly, at the level of RyR2, the increase in PP1 activity more than outweighed the increase in CaMKII activity, resulting in reduced RyR phosphorylation at Ser-2814. Exaggerated CaMKII activation due to counterregulatory mechanisms upon loss of I-1 is an important caveat with respect to suggested therapeutic I-1-inhibition, as CaMKII overactivity has been heavily implicated in several cardiac pathologies.

Morbidity and mortality after bilateral simultaneous total knee arthroplasty in a fast-track setting.

Background and purpose - The safety aspects of bilateral simultaneous total knee arthroplasty (BSTKA) are still debated. In this retrospective single-center study, we investigated early morbidity and mortality following BSTKA in a modern fast-track setting. We also identified risk factors for re-admission within 90 days and for a length of stay (LOS) of more than 5 days. Patients and methods - 284 patients were selected to receive BSTKA at our institution from 2008 through 2014 in a well-described, standardized fast-track setup (Husted 2012a, b). All re-admissions within 90 days were identified and mortality rates and time until death were recorded. Transfusion rates and numbers of transfusions were also recorded. Logistic regression analysis was used to identify risk factors for re-admission within 90 days, and also for a LOS of more than 5 days. Results - 90-day mortality was 0%. 10% of the patients were re-admitted within 90 days. Median time to re-admission was 18 (3-75) days. 153 patients (54%) received postoperative blood transfusions. An ASA score of 3 was identified as an independent risk factor for re-admission within 90 days (OR = 5, 95% CI: 1.3-19) and for LOS of > 5 days (OR = 6, 95% CI: 1.6-21). Higher BMI was a weak risk factor for re-admission within 90 days. Interpretation - BSTKA in selected patients without cardiopulmonary disease in a fast-track setting appears to be safe with respect to early postoperative morbidity and mortality. Surgeons should be aware that patients with an ASA score of 3 have an increased risk of re-admission and a prolonged length of stay, while patients with higher BMI have an increased risk of re-admission following BSTKA.

Removal of restrictions following primary THA with posterolateral approach does not increase the risk of early dislocation.

BACKGROUND AND PURPOSE: Patient education and mobilization restrictions are often used in an attempt to reduce the risk of dislocation following primary THA. To date, there have been no studies investigating the safety of removal of mobilization restrictions following THA performed using a posterolateral approach. In this retrospective non-inferiority study, we investigated the rate of early dislocation following primary THA in an unselected patient cohort before and after removal of postoperative mobilization restrictions. PATIENTS AND METHODS: From the Danish National Health Registry, we identified patients with early dislocation in 2 consecutive and unselected cohorts of patients who received primary THA at our institution from 2004 through 2008 (n = 946) and from 2010 through 2014 (n = 1,329). Patients in the first cohort were mobilized with functional restrictions following primary THA whereas patients in the second cohort were allowed unrestricted mobilization. Risk of early dislocation (within 90 days) was compared in the 2 groups and odds ratio (OR)-adjusted for possible confounders-was calculated. Reasons for early dislocation in the 2 groups were identified. RESULTS: When we adjusted for potential confounders, we found no increased risk of early dislocation within 90 days in patients who were mobilized without restrictions. Risk of dislocation within 90 days was lower (3.4% vs 2.8%), risk of dislocation within 30 days was lower (2.1% vs 2.0%), and risk of multiple dislocations (1.8% vs 1.1%) was lower in patients who were mobilized without restrictions, but not statistically significantly so. Increasing age was an independent risk factor for dislocation. INTERPRETATION: Removal of mobilization restrictions from the mobilization protocol following primary THA performed with a posterolateral approach did not lead to an increased risk of dislocation within 90 days.

Do patients care about higher flexion in total knee arthroplasty? A randomized, controlled, double-blinded trial.

BACKGROUND: Little information exists to support that patients care about flexion beyond what is needed to perform activities of daily living (ADL) after Total knee arthroplasty (TKA). The purpose of this study was to investigate if the achievement of a higher degree of knee flexion after TKA would result in a better patient perceived outcome. METHODS: The study is a randomized, double-blinded, controlled trial in which 36 patients (mean age: 67.2 yrs) undergoing one-stage bilateral TKA randomly received a standard cruciate-retaining (CR) TKA in one knee and a high-flex posterior-stabilized (PS) TKA in the contra lateral knee. At follow-up ROM, satisfaction, pain, "feel" of the knee and the abilities in daily activities were assessed. RESULTS: At 1-year follow-up we found an expected significantly higher degree of knee flexion of 7° in the high-flex knees (p = 0.001). The high-flex TKA's showed a mean active flexion of 121°. In both TKA's the median VAS pain score was 0, the median VAS satisfaction score was 9, and the median VAS score of the patient "feel" of the knee was 9 at 1-year follow-up. Further, there were no significant differences between the knees in the performance of daily activities. CONCLUSIONS: As expected the high-flex TKA showed increased knee flexion, but no significant differences in the patient perceived outcomes were found. This suggests little relevance to the patients of the difference in knee flexion - when flexion is of this magnitude - as pain free ROM and high patient satisfaction were achieved with both TKA's. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00294528.

Indications for knee arthroplasty have remained consistent over time.

INTRODUCTION: Between 2004 and 2009, the incidence of primary total knee arthroplasty (TKA) in Denmark has almost doubled. It has been speculated that this increase may be a result of patients being operated on weaker indications. The purpose of this study was to compare preoperative degrees of osteoarthritis and health-related quality of life (QoL) in patients receiving primary TKA in 2004 and 2009. MATERIAL AND METHODS: We identified 154 and 369 primary TKAs inserted at our institution in 2004 and 2009, respectively. Patients had been invited to complete the Short Form (SF)-36 questionnaire preoperatively. Two groups of patients that were representative with regard to age and gender were randomly sampled and compared (n = 44 in 2004 versus n = 106 in 2009). The Kellgren-Lawrence (K-L) grade of osteoarthritis was assessed on preoperative radiographs in all patients. RESULTS: We found no statistically significant differences in gender distribution or mean age at surgery. We reached K-L grades of 3-4 in 52.4% and 49.6% in 2004 and 2009, respectively (p = 0.57). The preoperative mean SF-36 physical component scores were 32.6 and 33.7, respectively (p = 0.44). The preoperative mean SF-36 mental component scores were 43.0 in 2004 and 49.3 (i.e. 6.3 points higher) in 2009 (p = 0.003). CONCLUSION: Preoperative degrees of osteoarthritis and physical health-related QoL did not change from 2004 to 2009. Thus, it seems that these components of operative indications have not weakened. The increased preoperative SF-36 mental component score of these patients may have had a positive effect on postoperative outcomes. FUNDING: not relevant. TRIAL REGISTRATION: not relevant. TRIAL REGISTRATION: not relevant.

High-volume infiltration analgesia in bilateral hip arthroplasty. A randomized, double-blind placebo-controlled trial.

BACKGROUND AND PURPOSE: High-volume infiltration analgesia may be effective in postoperative pain management after hip arthroplasty but methodological problems prevent exact interpretation of previous studies. METHODS: In a randomized, double-blind placebo-controlled trial in 12 patients undergoing bilateral total hip arthroplasty (THA) in a fast-track setting, saline or high-volume (170 mL) ropivacaine (0.2%) with epinephrine (1:100,000) was administered to the wound intraoperatively along with supplementary postoperative injections via an intraarticular epidural catheter. Oral analgesia was instituted preoperatively with a multimodal regimen (gabapentin, celecoxib, and acetaminophen). Pain was assessed repeatedly for 48 hours postoperatively, at rest and with 45° hip flexion. RESULTS: Pain scores were low and similar between ropivacaine and saline administration. Median hospital stay was 4 (range 2-7) days. Interpretation Intraoperative high-volume infiltration with 0.2% ropivacaine with repeated intraarticular injections postoperatively may not give a clinically relevant analgesic effect in THA when combined with a multimodal oral analgesic regimen with gabapentin, celecoxib, and acetaminophen.

Bilateral simultaneous total hip arthroplasty in a fast track setting.

Simultaneous bilateral hip arthroplasty has been reported to have varying results in the literature when performed using conventional postoperative care. Unilateral hip and knee arthroplasty as well as bilateral simultaneous knee arthroplasty may be associated with reduced length of stay and low complication rates when performed in a fast-track setting. We believed it would be useful to assess hip arthroplasty in this context, and we report 50 consecutive fast-track simultaneous bilateral hip arthroplasty procedures. The median length of stay was 4 days. Mortality within 90 days was 4% and 8% required a further operative procedure. The overall complication rate was 22%. 55% of the complications were considered to be caused by failures in surgical technique and 45% by other factors. Bilateral simultaneous hip arthroplasty may have a high complication rate in a fast-track setting and further evaluation may be warranted.

Intraoperative local infiltration analgesia for early analgesia after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial.

BACKGROUND AND OBJECTIVES: High-volume local infiltration analgesia (LIA) is widely applied as part of a multimodal pain management strategy in total hip arthroplasty (THA). However, methodological problems hinder the exact interpretation of previous trials, and the evidence for LIA in THA remains to be clarified. Therefore, we evaluated whether intraoperative high-volume LIA, in addition to a multimodal oral analgesic regimen, would further reduce acute postoperative pain after THA. METHODS: Patients scheduled for unilateral, primary THA under spinal anesthesia were included in this randomized, double-blind, placebo-controlled trial receiving high-volume (150 mL) wound infiltration with ropivacaine 0.2% with epinephrine (10 µg/mL) or saline 0.9%. A multimodal oral analgesic regimen consisting of slow-release acetaminophen 2 g, celecoxib 400 mg, and gabapentin 600 mg was instituted preoperatively. Rescue analgesic consisted of oral oxycodone. Pain was assessed repeatedly the first 8 hrs after surgery using the 100-mm visual analog scale. The primary end point was pain during walking (5 m) 8 hrs after surgery. Secondary end points were pain at rest, pain on 45 degrees of passive flexion of the hip with the leg straight, and cumulative consumption of oxycodone. RESULTS: A total of 120 patients were included. Pain during walking (median [interquartile range] [95% confidence interval]) was low in the ropivacaine versus the placebo group (20 [14-38] [0-93] vs 22 [10-40] [0-83]) and did not differ significantly (P = 0.71). Consumption of rescue oxycodone (5 mg [0-10 mg] [0-24 mg] vs 10 mg [0-15 mg] [0-29 mg]) did not differ (P = 0.45). CONCLUSIONS: Intraoperative high-volume LIA with ropivacaine 0.2% provided no additional reduction in acute pain after THA when combined with a multimodal oral analgesic regimen consisting of acetaminophen, celecoxib, and gabapentin and is therefore not recommended.

Fast-track revision knee arthroplasty. A feasibility study.

BACKGROUND AND PURPOSE: Fast-track surgery has reduced the length of hospital stay (LOS), morbidity, and convalescence in primary hip and knee arthroplasty (TKA). We assessed whether patients undergoing revision TKA for non-septic indications might also benefit from fast-track surgery. METHODS: 29 patients were operated with 30 revision arthroplasties. Median age was 67 (34-84) years. All patients followed a standardized fast-track set-up designed for primary TKA. We determined the outcome regarding LOS, morbidity, mortality, and satisfaction. RESULTS: Median LOS was 2 (1-4) days excluding 1 patient, who was transferred to another hospital for logistical reasons (10 days). None of the patients died within 3 months, and 3 patients were re-admitted (2 for suspicion of DVT, which was not found, and 1 for joint mobilization). Patient satisfaction was high. INTERPRETATION: Patients undergoing revision TKA for non-septic reasons may be included in fast-track protocols. Outcome appears to be similar to that of primary TKA regarding LOS, morbidity, and satisfaction. Our findings call for larger confirmatory studies and studies involving other indications (revision THA, 1-stage septic revisions).

Low risk of thromboembolic complications after fast-track hip and knee arthroplasty.

BACKGROUND AND PURPOSE: Pharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10­35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization. PATIENTS AND METHODS: 1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004­2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6­8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS). RESULTS: The mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1­4 days), the mortality was 0% (95% CI: 0­0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2­2.2), in THA it was 0.51% (CI: 0.1­1.8), and in BSTKA it was 0% (CI: 0­2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1­1.7), in THA it was 0% (CI: 0­1.0), and in BSTKA it was 0% (CI: 0­2.9). INTERPRETATION: The risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.

Readmissions after fast-track hip and knee arthroplasty.

INTRODUCTION: With the implementation of fast-track surgery with optimization of both logistical and clinical features, the postoperative convalescence has been reduced as functional milestones have been achieved earlier and consequently length of stay (LOS) in hospital has been reduced. However, it has been speculated that a decrease in LOS may be associated with an increase in readmissions in general, including risk of dislocation after total hip arthroplasty (THA) or manipulation after total knee arthroplasty (TKA). MATERIALS AND METHODS: 1,731 consecutive, unselected patients were operated with primary THA or TKA in a well-described standardized fast-track setup from 2004 to 2008. All readmissions and deaths within 90 days were analyzed using the national health register. RESULTS: Mean LOS decreased from 6.3 to 3.1 days. Within 90 days, 15.6% of patients following TKA were readmitted as opposed to 10.9% after THA (p = 0.005). Three deaths (0.17%) were associated with clotting episodes. Suspicion of DVT (not found) and suspicion of infection made up half of the readmissions. Readmissions in general and for thromboembolic events, dislocations and manipulations in specific did not increase with decreasing LOS. There was no difference between readmission rates per year for either TKA or THA but there was a significantly reduced risk of dislocation found with decreasing LOS comparing each year from 2005 to 2007 with the index year of 2004 (with the longest LOS and the highest incidence of dislocation). CONCLUSION: Fast-track TKA and THA do not increase the readmission rate. Readmissions are more frequent after TKA than THA, but dislocation after THA and manipulation after TKA do not increase as LOS is decreasing.

Wound spread of radiolabeled saline with multi- versus few-hole catheters.

BACKGROUND AND OBJECTIVES: Continuous wound infusion of local anesthetics is effective in postoperative pain management and may be useful in major joint arthroplasty, but the optimal technique for postoperative administration of local anesthetics in the wound awaits trials evaluating the optimal type of catheter (single-, few-, or multiholed catheters). METHODS: Sixteen patients undergoing total hip arthroplasty were randomized to intraoperative subfascial placement of a triple-orifice epidural catheter or a 15-cm multiholed catheter. Twenty milliliters of technetium Tc 99m diethylenetriaminepentaacetic acid-labeled saline was injected postoperatively and wound spread for 10 mins was recorded with a double-head gamma camera. RESULTS: Mean (SD) wound spread (cm(2)) was the same with administration through a multiholed catheter versus the epidural catheter in both anterior (89 [15] versus 82 [20], P = 0.4) and lateral (68 [19] versus 60 [11], P = 0.3) projections. CONCLUSIONS: Wound spread of a bolus injection through 15-cm multiholed catheters versus triple-orifice epidural catheters is similar with subfascial catheter placement in total hip arthroplasty. Procedure-specific trials are required to evaluate the analgesic efficacy of postoperative administration of local anesthetic in the wound with different types of catheter before general recommendations can be made.

A compression bandage improves local infiltration analgesia in total knee arthroplasty.

BACKGROUND: High-volume local infiltration analgesia has been shown to be an effective pain treatment after knee replacement, but the role of bandaging to prolong analgesia has not been evaluated. METHODS: 48 patients undergoing fast-track total knee replacement with high-volume (170 mL) 0.2% ropivacaine infiltration analgesia were randomized to receive a compression or a non-compression bandage, and pain was assessed at rest and with mobilization at regular intervals for 24 h postoperatively. RESULTS: Pain at rest, during flexion, or on straight leg lift was lower for the first 8 h in patients with compression bandage than in those with non-compression bandage and with a similar low use of oxycodone. Mean hospital stay was similar (2.8 days and 3.3 days, respectively). INTERPRETATION: A compression bandage is recommended to improve analgesia after high-volume local infiltration analgesia in total knee arthroplasty.

Local anesthetics after total knee arthroplasty: intraarticular or extraarticular administration? A randomized, double-blind, placebo-controlled study.

BACKGROUND: High-volume local infiltration analgesia with additional intraarticular and wound administration of local anesthetic has been shown to be effective after knee replacement, but the optimum site of administration of the local anesthetic (i.e. intraarticular or extraarticular) has not been evaluated. PATIENTS AND METHODS: 32 patients undergoing total knee replacement with high-volume (170 mL) 0.2% ropivacaine infiltration analgesia were randomized to receive injection of 20 mL ropivacaine (0.2%) intraarticularly plus 30 mL saline in the extraarticular wound space 24 hours postoperatively or to receive 20 mL ropivacaine (0.2%) intraarticularly plus 30 mL ropivacaine (0.2%) in the extraarticular wound space 24 hours postoperatively. Pain intensity at rest and with mobilization was recorded for 4 hours after administration of additional local anesthetics. RESULTS: Intensity of pain at rest, during flexion, or straight leg lift was not statistically significantly different between the two groups, but there was a tendency of improved analgesia with administration of additional local anesthetic in the extraarticular wound space. INTERPRETATION: The optimal site of administration of local anesthetic in total knee arthroplasty cannot be determined from the present study. However, the insignificant analgesic effect from additional administration of extraarticular local anaesthetic may have been due to the relatively low pain scores observed 24 h postoperatively, confirming the efficiency of the high-volume infiltration analgesia technique. Further studies are required to define the optimal site of administration of local anesthetic following knee replacement surgery.