Temporal changes in sleep quality and knee function following primary total knee arthroplasty: a prospective study.

PURPOSE: Several patient-reported outcome measures (PROMs) have been used to assess improvement in the quality of life following total knee arthroplasty (TKA). However, there is paucity of studies evaluating the sleep quality and knee function following TKA. The primary aim of our study was to evaluate the sleep quality and knee function in primary TKA patients using the Pittsburgh Sleep Quality Index (PSQI) and Knee Society Score (KSS), respectively. The secondary aim was to assess the correlation between the two outcome measures over the course of first post-operative year following TKA. METHODS: One hundred sixty-eight patients (female-140/male-28) with mean age of 64.63 years (± 7.50) who underwent 168 primary unilateral TKA using a cemented posterior-stabilised implant without patella resurfacing between June 2018 and October 2018 were included in the study. Global PSQI and KSS were recorded pre-operatively and post-operatively weekly up to six weeks and at one year. Body mass index (BMI) and Charlson comorbidity index (CCI) were recorded during pre-operative assessment. RESULTS: Mean(± SD) BMI and CCI were 28.45(± 4.64) and 2.48(± 0.93), respectively. Pre-operative global PSQI of 1.98(± 0.97) increased to 13.48(± 3.36) in the first post-operative week (p < 0.001) and remained high during all the six weeks following TKA (p < 0.001), whereas at the first post-operative year, it reduced to 2.10(± 1.15) (p = 0.15). Pre-operative KSS of 52.00(± 9.98) increased to 71.67(± 6.58) and 85.49(± 4.67) at 6 weeks and the first post-operative year respectively (p < 0.001). Pre-operative global PSQI had moderate correlation with pre-operative KSS (r = 0.39) (p < 0.001). Strong correlation was noted between pre-operative global PSQI and six week post-operative KSS (r = 0.47) (p < 0.001). Low correlation was noted between pre-operative global PSQI and KSS at the first post-operative year (r = 0.10, p = 0.19) following TKA. Multiple regression analysis revealed age, CCI, and pre-operative range of motion as independent predictors of global PSQI. CONCLUSIONS: Patients undergoing TKA experience changes in sleep quality but report an overall improvement in knee function during the first post-operative year. Sleep quality has moderate to strong correlation with knee function in the early post-operative period beyond which there is a low correlation with knee function thereby suggesting a transient phenomenon. Hence patients undergoing TKA can be appropriately counselled regarding the variation in sleep quality in the post-operative period and reassured accordingly.

Autologous cell-free serum preparations in the management of knee osteoarthritis: what is the current clinical evidence?

BACKGROUND: There is paucity in the current literature regarding clinical outcomes of autologous cell-free serum preparations. The objective of this paper is to collate the clinical evidence and review the results of intraarticular injections of autologous cell-free serum preparations in the management of knee osteoarthritis (OA). METHODS: A comprehensive English literature search was undertaken using the healthcare database website (https://hdas.nice.org.uk/). The PubMed, Medline, CINAHL, Embase and the Cochrane library databases were searched to identify all studies of autologous protein solution/autologous conditioned serum (ACS/APS) in the management of knee OA. We evaluated the reported clinical outcomes with respect to pain, function, morbidity, adverse effects and complications. RESULTS: Fifteen relevant articles were identified in the current literature. Outcomes following injection of ACS/APS have been reported in patients with age range (34-87 years) and unilateral or bilateral knee OA. Seven studies reported improvement in visual analog scale (VAS) whereas the Western Ontario and McMaster Universities osteoarthritis instrument (WOMAC) score improved in nine studies. Considerable variation was noted in the injection technique and duration of post-procedure assessment with only one study reporting long-term follow-up beyond 24 months. Joint swelling and injection-site pain were reported to be the most common complications; only one study reported a case of septic arthritis. However, no evidence is available to clearly identify factors that may predict the outcomes following this procedure. CONCLUSION: Current data from the clinical studies would suggest that the intraarticular administration of autologous cell-free serum preparations, such as ACS/APS, in patients with knee OA may improve pain and function, with limited morbidity. High-quality clinical trials with stratified patient cohorts, longer follow-up duration and robust reporting of outcome measures are essential to improve the understanding of the indications and clinical effectiveness of these novel products.

Subclinical neuropathy in diabetic patients: a risk factor for bilateral lower limb neurological deficit following spinal anesthesia?

Total knee arthroplasty performed under spinal or general anesthesia is a common successful orthopedic procedure. Nonetheless, in patients with diabetes mellitus this procedure can present unique challenges to orthopedic surgeon and anesthesiologist alike. We describe a case of an elderly male diabetic patient who developed bilaterally symmetrical lower limb neurological deficit following an uneventful total knee arthroplasty performed under spinal anesthesia. Postoperative nerve conduction study with electromyography confirmed symmetrical extensive denervation of lower limb muscles, including low-voltage fibrillation potentials and positive sharp waves. These findings were consistent with a preexisting neuropathy, thereby suggesting a subclinical neuropathy as a potential risk factor for this neurological complication. Our case highlights the fact that patients with longstanding comorbidities, namely peripheral vascular disease and diabetes mellitus, may be at an increased risk of neurological injury following regional anesthesia. Hence, we believe that preoperative evaluation of diabetic patients should include neurophysiological studies to identify subclinical neuropathy and minimize the risk of neurological injury.

Lower limb elevation: useful and effective technique of exsanguination prior to knee arthroscopy.

The use of a Rhys-Davies (R-D) mechanical exsanguinator prior to the application of tourniquet is routine clinical practice in knee arthroscopy. However, this technique has been reported to cause injuries and is contraindicated in conditions like malignancy and latex allergy. Lower limb elevation alone has also been described as a technique of exsanguination. We conducted a prospective audit of two groups of patients (25 each) undergoing routine knee arthroscopy comparing the practice of mechanical exsanguination (R-D) with lower limb elevation technique. Average total operative times of the two groups were similar (R-D exsanguinator-23 min, limb elevation-21 min, n.s). Time interval between tourniquet inflation and skin incision was significantly lower in limb elevation technique (R-D exsanguinator-5 min, limb elevation-0.2 min, P < 0.001). Limb elevation technique of exsanguination helps avoid the risks associated with mechanical exsanguination and may potentially reduce the non-operative tourniquet application time.