Neuraxial anaesthesia techniques and postoperative outcomes among joint arthroplasty patients: is spinal anaesthesia the best option?

BACKGROUND: Neuraxial anaesthesia is frequently used for lower limb arthroplasty but it is unclear whether benefits vary among patients receiving different subtypes of neuraxial anaesthesia. We evaluated whether differences in risk for adverse postoperative outcomes exist between patients receiving combined spinal and epidural (CSE), epidural, or spinal anaesthesia. METHODS: In this retrospective cohort study, we identified 40 852 patients who underwent total hip and knee arthroplasty (THA and TKA) procedures under neuraxial anaesthesia (34 301 CSE, 2464 epidural, 4087 spinal) between 2005 and 2014 at a single institution. We used multivariable logistic regression to evaluate the following outcomes: cardiac, pulmonary, gastrointestinal, renal/genitourinary, and thromboembolic complications, and prolonged length of stay. RESULTS: Compared with CSE, spinal anaesthesia was associated with reduced adjusted odds for cardiac [odds ratio (OR), 0.68; 95% confidence interval (CI), 0.52-0.89], pulmonary (OR: 0.51; 95% CI: 0.38-0.68), gastrointestinal (OR: 0.50; 95% CI: 0.32-0.78), and thromboembolic complications (OR: 0.40; 95% CI: 0.23-0.73), and prolonged length of stay (OR: 0.72; 95% CI: 0.66-0.80). Patients who received epidural anaesthesia did not have significantly different odds for any outcomes compared with CSE patients. CONCLUSIONS: We identified clear differences in risk for certain postoperative events by subtype of neuraxial anaesthesia, suggesting that spinal anaesthesia is associated with the most favourable outcomes profile.

Postoperative delirium in total knee and hip arthroplasty patients: a study of perioperative modifiable risk factors.

BACKGROUND: Postoperative delirium continues to pose major clinical difficulties. While unmodifiable factors (e.g. age and comorbidity burden) are commonly studied risk factors for delirium, the role of modifiable factors, such as anaesthesia type and commonly used perioperative medications, remains understudied. This study aims to evaluate the role of modifiable factors for delirium after hip and knee arthroplasties. METHODS: We performed a retrospective study of 41 766 patients who underwent hip or knee arthroplasties between 2005 and 2014 at a single institution. Data were collected as part of routine patient care. Multivariable logistic regression models assessed associations between anaesthesia type and commonly used perioperative medications (opioids, benzodiazepines, and ketamine) and postoperative delirium. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Various sensitivity analyses are also considered, including multiple imputation methods to address missing data. RESULTS: Postoperative delirium occurred in 2.21% (n=922) of all patients. While patients who received neuraxial anaesthesia were at lower risk for postoperative delirium (compared with general anaesthesia; epidural OR 0.59 CI 0.38-0.93; spinal OR 0.55 CI 0.37-0.83; combined spinal/epidural OR 0.56 CI 0.40-0.80), those given intraoperative ketamine (OR 1.27 CI 1.01-1.59), opioids (OR 1.25 CI 1.09-1.44), postoperative benzodiazepines (OR 2.47 CI 2.04-2.97), and ketamine infusion (OR 10.59 CI 5.26-19.91) were at a higher risk. CONCLUSIONS: In this cohort of hip and knee arthroplasty patients, anaesthesia type and perioperative medications were associated with increased odds for postoperative delirium. Our results support the notion that modifiable risk factors may exacerbate or attenuate risk for postoperative delirium.

Dislocation following total hip arthroplasty using dual mobility acetabular components: a systematic review.

AIMS: The aim of this systematic review was to report the rate of dislocation following the use of dual mobility (DM) acetabular components in primary and revision total hip arthroplasty (THA). MATERIALS AND METHODS: A systematic review of the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was performed. A comprehensive search of Pubmed/Medline, Cochrane Library and Embase (Scopus) was conducted for English articles between January 1974 and March 2016 using various combinations of the keywords "dual mobility", "dual-mobility", "tripolar", "double-mobility", "double mobility", "hip", "cup", "socket". The following data were extracted by two investigators independently: demographics, whether the operation was a primary or revision THA, length of follow-up, the design of the components, diameter of the femoral head, and type of fixation of the acetabular component. RESULTS: In all, 59 articles met our inclusion criteria. These included a total of 17 908 THAs which were divided into two groups: studies dealing with DM components in primary THA and those dealing with these components in revision THA. The mean rate of dislocation was 0.9% in the primary THA group, and 3.0% in the revision THA group. The mean rate of intraprosthetic dislocation was 0.7% in primary and 1.3% in revision THAs. CONCLUSION: Based on the current data, the use of DM acetabular components are effective in minimising the risk of instability after both primary and revision THA. This benefit must be balanced against continuing concerns about the additional modularity, and the new mode of failure of intraprosthetic dislocation. Longer term studies are needed to assess the function of these newer materials compared with previous generations. Cite this article: Bone Joint J 2017;99-B(1 Supple A):18-24.

Meta-analysis of cause of death following total joint replacement using different thromboprophylaxis regimens.

We performed a meta-analysis of modern total joint replacement (TJR) to determine the post-operative mortality and the cause of death using different thromboprophylactic regimens as follows: 1) no routine chemothromboprophylaxis (NRC); 2) Potent anticoagulation (PA) (unfractionated or low-molecular-weight heparin, ximelagatran, fondaparinux or rivaroxaban); 3) Potent anticoagulation combined (PAC) with regional anaesthesia and/or pneumatic compression devices (PCDs); 4) Warfarin (W); 5) Warfarin combined (WAC) with regional anaesthesia and/or PCD; and 6) Multimodal (MM) prophylaxis, including regional anaesthesia, PCDs and aspirin in low-risk patients. Cause of death was classified as autopsy proven, clinically certain or unknown. Deaths were grouped into cardiopulmonary excluding pulmonary embolism (PE), PE, bleeding-related, gastrointestinal, central nervous system, and others (miscellaneous). Meta-analysis based on fixed effects or random effects models was used for pooling incidence data. In all, 70 studies were included (99 441 patients; 373 deaths). The mortality was lowest in the MM (0.2%) and WC (0.2%) groups. The most frequent cause of death was cardiopulmonary (47.9%), followed by PE (25.4%) and bleeding (8.9%). The proportion of deaths due to PE was not significantly affected by the thromboprophylaxis regimen (PA, 35.5%; PAC, 28%; MM, 23.2%; and NRC, 16.3%). Fatal bleeding was higher in groups relying on the use of anticoagulation (W, 33.8%; PA, 9.4%; PAC, 10.8%) but the differences were not statistically significant. Our study demonstrated that the routine use of PA does not reduce the overall mortality or the proportion of deaths due to PE.

Complex regional pain syndrome type I as a consequence of trauma or surgery to upper extremity: management with intravenous regional anaesthesia, using lidocaine and methyloprednisolone.

Complex regional pain syndrome type I (CRPS-I) is a known complication after surgery or trauma to the upper extremity and is difficult to treat. A simple and easily tolerated method of treatment that includes intravenous regional anaesthetic block with lidocaine and methyloprednisolone is presented. One hundred and sixty-eight patients with CRPS-I of the upper extremity were treated in a 5-year period. At the end of treatment 88% of the patients reported minimal or no pain. After a mean follow-up of 5 years (range 28 months to 7 years) complete absence of pain was reported by 92% of patients. The symptoms of the acute phase of the syndrome were reversed. Early recognition and prompt initiation of treatment is very important for the course of the disease as symptoms can be reversible when treatment starts early. Permanent results with a functional upper extremity and very satisfactory pain relief can be anticipated.

Do steroids, conventional non-steroidal anti-inflammatory drugs and selective Cox-2 inhibitors adversely affect fracture healing?

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used drugs worldwide. They are prescribed for orthopaedic conditions such as osteoarthritis, soft-tissue injuries and fractures. The new generation of NSAIDs, selective cyclooxygenase-2 (COX-2) inhibitors, exhibit analgesic and anti-inflammatory effects equivalent or superior to conventional NSAIDs, while reducing the prevalence of adverse gastrointestinal events. Several reports from animal and in vitro studies have demonstrated impaired bone healing in the presence of conventional NSAIDs, as measured by a variety of different parameters. More recently, initial studies investigating the effects of selective COX-2 inhibitors on bone healing have yielded similar results, while other reports showed minor or no impairment of the healing process. The purpose of the present review article is the thorough review and analysis of the past 50-year literature and the attempt to get some conclusions about the effect of NSAIDs and selective COX-2 inhibitors on fracture healing and the clinical significance of their use in the management of postoperative and post-fracture pain.

Total knee replacement performed with either a mini-midvastus or a standard approach: a prospective randomised clinical and radiological trial.

We report the clinical and radiological results of a two- to three-year prospective randomised study which was designed to compare a minimally-invasive technique with a standard technique in total knee replacement and was undertaken between January 2004 and May 2007. The mini-midvastus approach was used on 50 patients (group A) and a standard approach on 50 patients (group B). The mean follow-up in both groups was 23 months (24 to 35). The functional outcome was better in group A up to nine months after operation, as shown by statistically significant differences in the mean function score, mean total score and the mean Oxford knee score (all, p = 0.05). Patients in group A had statistically significant greater early flexion (p = 0.04) and reached their greatest mean knee flexion of 126.5 degrees (95 degrees to 135 degrees ) 21 days after operation. However, at final follow-up there was no significant difference in the mean maximum flexion between the groups (p = 0.08). Technical errors were identified in six patients from group A (12%) on radiological evaluation. Based on these results, the authors currently use minimally-invasive techniques in total knee replacement in selected cases only.

Increased oxacillin resistance in thigh pyomyositis in diabetic patients.

UNLABELLED: Thigh abscesses due to pyomyositis are uncommon. To guide empiric antibiotic therapy in diabetics we determined the rate of such infections due to oxacillin-resistant Staphylococcus aureus and Gram-negative organism infections, and whether the occurrence of oxacillin-resistant pathogens increased during the study period. We retrospectively reviewed 39 adult patients with diabetes mellitus treated for a deep thigh abscess. There were 29 men and 10 women; their mean age was 45 years. Comorbidities were present in 15 patients. S. aureus was the most common pathogen, present in 82% (32/39) of our patients. Gram-negative organisms were cultured in 14% (6/39) of patients and anaerobes in 10% (4/39). The infection was polymicrobial in 12 of 39 patients (31%). Oxacillin-resistant S. aureus comprised 25% (8/32) of infections due to S. aureus. Oxacillin-resistance increased during the last 3 years of this study from one of 18 S. aureus isolates from 1994 to 2004 to seven of 14 isolates from 2004 to 2006. In diabetic patients with thigh pyomyositis, empiric antibiotic therapy should provide broad spectrum coverage for oxacillin-resistant S. aureus, Gram-negative, as well as anaerobic organisms. LEVEL OF EVIDENCE: Level IV, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.

The effects of the short-term administration of low therapeutic doses of anti-COX-2 agents on the healing of fractures. An experimental study in rabbits.

We have evaluated the effect of the short-term administration of low therapeutic doses of modern COX-2 inhibitors on the healing of fractures. A total of 40 adult male New Zealand rabbits were divided into five groups. A mid-diaphyseal osteotomy of the right ulna was performed and either normal saline, prednisolone, indometacin, meloxicam or rofecoxib was administered for five days. Radiological, biomechanical and histomorphometric evaluation was performed at six weeks. In the group in which the highly selective anti-COX-2 agent, rofecoxib, was used the incidence of radiologically-incomplete union was similar to that in the control group. All the biomechanical parameters were statistically significantly lower in both the prednisolone and indometacin (p = 0.01) and in the meloxicam (p = 0.04) groups compared with the control group. Only the fracture load values were found to be statistically significantly lower (p = 0.05) in the rofecoxib group. Histomorphometric parameters were adversely affected in all groups with the specimens of the rofecoxib group showing the least negative effect. Our findings indicated that the short-term administration of low therapeutic doses of a highly selective COX-2 inhibitor had a minor negative effect on bone healing.