RESUMEN
BACKGROUND: Incisional dressings may decrease wound complications and joint infection after total hip and knee arthroplasties (THA; TKA). However, there is no consensus on the superiority of a particular product. This study compared infection and wound complications among randomized controlled trials (RCTs) across various dressing types after primary THA and TKA. METHODS: Scopus, Ovid/MEDLINE, PubMed, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials were queried in May 2024. A frequentist model network meta-analysis of eligible prospective RCTs compared minor and major wound complications and dressing changes using P-scores. RESULTS: Of 3,067 compiled studies, 12 RCTs of 1,939 patients with median (interquartile range) follow-up of 42 (382) days undergoing primary THA (n = 880, 45.4%) or TKA (n = 1,059, 54.6%) with alginate (n = 208; 10.7%), absorbent (n = 236; 12.2%), gauze (n = 474; 24.4%), or hydrofiber (n = 683; 35.2%) dressings or negative-pressure wound therapy (NPWT; n = 338; 17.4%) were included for meta-analysis. Compared with gauze, alginate and hydrofiber dressings were associated with fewer postoperative changes (mean difference [MD], -12.1; 95% confidence interval [CI], -15.08 to -9.09, p < 0.001; MD, -3.5; 95% CI, -6.30 to -0.74, p = 0.013, respectively). In a subanalysis, silver-ion hydrofiber also was associated with fewer changes (MD, -5.0; 95% CI, -5.70 to -4.39; p < 0.001). Overall, there was no statistically significant risk of increased minor nor major wound complications including superficial and deep infections among all dressing types and NPWT compared with gauze. CONCLUSION: Despite no association between wound complications nor infection risk among various incisional dressings and NPWT vs. gauze, the alginate, hydrofiber, and silver hydrofiber dressings had statistically fewer mean postoperative changes. Future studies are required to assess whether these dressings confer reduced infection risk. LEVEL OF EVIDENCE: Therapeutic, Level I. See Instructions for Authors for a complete description of levels of evidence.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Vendajes , Terapia de Presión Negativa para Heridas , Metaanálisis en Red , Ensayos Clínicos Controlados Aleatorios como Asunto , Infección de la Herida Quirúrgica , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Cadera/efectos adversos , Infección de la Herida Quirúrgica/prevención & control , Infección de la Herida Quirúrgica/etiologíaRESUMEN
¼ Perioperative corticosteroids are strongly recommended for reducing the incidence and severity of postoperative nausea and vomiting following elective total hip or total knee arthroplasty.¼ Corticosteroids may reduce postoperative pain and opioid requirements. Similarly, corticosteroids appear to have a neutral-to-positive effect on length of stay, venous thromboembolism, mobility, delirium, acute kidney injury, and bone cement implantation syndrome (i.e., decreased length of stay).¼ Perioperative corticosteroids may induce hyperglycemia among both diabetic and nondiabetic patients; however, there is no strong evidence indicating that these transient corticosteroid-induced glycemic derangements may increase the risk of postoperative infectious complications.¼ The dosage and frequency of perioperative corticosteroid administration play a critical role in optimizing postoperative outcomes, with higher doses showing promise in reducing opioid consumption, postoperative pain, and length of stay.¼ The optimal dosage and frequency of corticosteroids remain unclear; however, the perioperative administration of 8 to 16 mg dexamethasone, or equivalent steroid, appears reasonable and safe in most cases.
Asunto(s)
Corticoesteroides , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Atención Perioperativa , Humanos , Artroplastia de Reemplazo de Cadera/efectos adversos , Corticoesteroides/administración & dosificación , Corticoesteroides/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Náusea y Vómito Posoperatorios/prevención & controlRESUMEN
BACKGROUND: Total knee arthroplasty (TKA) successfully alleviates pain from knee osteoarthritis, but muscle strength and function are reduced for a long period postoperatively. Postoperative active resistance exercise may play a relevant role. PURPOSE: To systematically evaluate effects of lower-limb active resistance exercise (ARE) on mobility, physical function, muscle strength and pain intensity in patients with TKA. METHODS: A search was conducted in PubMed, EMBASE, and Cochrane Library databases from inception to September 2023. Only randomized controlled trials (RCTs) that compared the effects of ARE and no intervention or other rehabilitation program without PRE were included. The outcome variables were mobility (Maximal walking speed [MWS]/6-Minute Walk Test[6MWT]), physical function (Stair Climb Test [SCT]/Timed Up and Go [TUG]), knee extension/ flexion power(KEP/KFP), joint range of motion (ROM) and pain. Standardized Mean Differences (SMD) or Mean Differences (MD) and 95% confidence intervals (CI) were calculated and combined in meta-analyses. The Cochrane Collaboration's Handbook were used for the methodological quality assessments. GRADE was used to assess the quality of evidence. The meta-analysis was performed using the RevMan 5.4 software. RESULTS: A total of 14 randomized controlled trials, involving 880 patients, were finally included. The lower-limb ARE exhibited significantly greater improvement in MWS (MD 0.13, 95%CI 0.08-0.18, P < 0.00001), TUG(MD -0.92, 95%CI -1.55- -0.28, P = 0.005), KEP (SMD 0.58, 95%CI 0.20-0.96, P = 0.003), KFP (SMD 0.38, 95%CI 0.13-0.63, P = 0.003), ROM-flexion (MD 2.74, 95%CI 1.82-3.67, P < 0.00001) and VAS (MD - 4.65, 95% CI - 7.86- -1.44, p = 0.005) compared to conventional exercise(CE) immediately post-intervention. However, there were no statistically significant differences between both groups in regard to 6MWT (MD 7.98, 95%CI -4.60-20.56, P = 0.21), SCT (MD -0.79, 95%CI -1.69-0.10, P = 0.08) and ROM-extension (MD -0.60, 95%CI -1.23-0.03, P = 0.06). CONCLUSIONS: According to the results of meta-analysis, patients undergoing TKA who receive the lower extremity ARE show better clinical effects in terms of pain relief, strength recovery and knee ROM. Simultaneously, it may be beneficial to improve mobility and physical function of patients after TKA.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Articulación de la Rodilla , Fuerza Muscular , Osteoartritis de la Rodilla , Rango del Movimiento Articular , Entrenamiento de Fuerza , Humanos , Artroplastia de Reemplazo de Rodilla/rehabilitación , Artroplastia de Reemplazo de Rodilla/efectos adversos , Articulación de la Rodilla/fisiopatología , Articulación de la Rodilla/cirugía , Fuerza Muscular/fisiología , Osteoartritis de la Rodilla/cirugía , Dimensión del Dolor , Dolor Postoperatorio/etiología , Dolor Postoperatorio/diagnóstico , Ensayos Clínicos Controlados Aleatorios como Asunto , Recuperación de la Función , Entrenamiento de Fuerza/métodos , Resultado del TratamientoRESUMEN
Aseptic loosening is a feared and not yet fully-understood complication of total knee arthroplasty (TKA). Hypersensitivity reactions may be the underlying cause within some susceptible patients. Metal-free implants have been developed as a possible solution. The aim of this prospective, observational long-term study was the assessment of a completely metal-free ceramic knee replacement system compared to its identical metal counterpart 8 years after implantation, conducted as a follow-up of a previous report. A total of 88 patients (mean age 69 years) were enrolled in this prospective, observational long-term 8-year follow-up study. The "ceramic group" with a completely metal-free total knee replacement system was compared to the "conventional group" with an identical metal TKA system at the final follow-up. Clinical assessment included Knee Society Score (KSS), Oxford Knee Score (OKS), European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-L), European Quality of Life 5 Dimension Visual Analogue Scale (EQ-VAS) and High Activity Arthroplasty Score (HAAS) as well as perioperative or postoperative complications and need for revision. The tibial/femoral positioning, signs of periprosthetic fissures/fractures or radiolucent lines were documented radiographically. All postoperative clinical scores in the ceramic group primarily improved from baseline to 4-year follow-up, but then decreased at the final 8-year follow-up. At the final follow-up, statistically non-significant differences were found in comparison of both groups for the KSS (ceramic: 166 ± 31, conventional: 162 ± 29; p > 0.05), OKS (ceramic: 37, conventional: 39; p > 0.05), EQ-VAS (ceramic: 77 ± 17, conventional: 72 ± 18; p > 0.05), and HAAS (ceramic: 8.29 ± 3.32, conventional: 9.28 ± 4.44; p > 0.05). A significant difference was found for EQ-5D-L (ceramic: 0.819 ± 0.284, conventional: 0.932 ± 0.126; p ≤ 0.05). Progressive radiolucent lines have been found around the uncemented tibial stem (0.8 mm at initial diagnosis (mean 19 months); 1.3 mm at 4-year follow-up; 1.6 mm at 8-year follow-up) without any clinical signs of loosening. One revision surgery was performed after a traumatic polyethylene inlay-breakage. No allergic reactions could be detected. The used ceramic TKA system meets the functional performance standards of an established identical metal TKA system after an 8-year follow-up period, offering a safe option for patients with prior hypersensitivity reactions to metallic materials. Full cementation of ceramic components is recommended.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Femenino , Anciano , Masculino , Estudios de Seguimiento , Prótesis de la Rodilla/efectos adversos , Persona de Mediana Edad , Estudios Prospectivos , Diseño de Prótesis , Calidad de Vida , Falla de Prótesis , Cerámica , Articulación de la Rodilla/cirugía , Anciano de 80 o más Años , Complicaciones Posoperatorias/etiología , Metales/efectos adversos , Resultado del TratamientoRESUMEN
BACKGROUND: Unicompartmental knee replacements (UKRs) are performed by surgeons at various stages in training with varying levels of supervision, but we do not know if this is a safe practice with comparable outcomes to consultant-performed UKR. The aim of this study was to use registry data for England and Wales to investigate the association between surgeon grade (consultant, or trainee), the senior supervision of trainees (supervised by a scrubbed consultant, or not), and the risk of revision surgery following UKR. METHODS AND FINDINGS: We conducted an observational study using prospectively collected data from the National Joint Registry for England and Wales (NJR). We included adult patients who underwent primary UKR for osteoarthritis (n = 106,206), recorded in the NJR between 2003 and 2019. Exposures were the grade of the operating surgeon (consultant, or trainee) and whether or not trainees were directly supervised by a consultant during the procedure (referred to as "supervised by a scrubbed consultant"). The primary outcome was all-cause revision surgery. The secondary outcome was the number of procedures revised for the following specific indications: aseptic loosening/lysis, infection, progression of osteoarthritis, unexplained pain, and instability. Flexible parametric survival models were adjusted for patient, operation, and healthcare setting factors. We included 106,206 UKRs in 91,626 patients, of which 4,382 (4.1%) procedures were performed by a trainee. The unadjusted cumulative probability of failure at 15 years was 17.13% (95% CI [16.44, 17.85]) for consultants, 16.42% (95% CI [14.09, 19.08]) for trainees overall, 15.98% (95% CI [13.36, 19.07]) for trainees supervised by a scrubbed consultant, and 17.32% (95% CI [13.24, 22.50]) for trainees not supervised by a scrubbed consultant. There was no association between surgeon grade and all-cause revision in either crude or adjusted models (adjusted HR = 1.01, 95% CI [0.90, 1.13]; p = 0.88). Trainees achieved comparable all-cause survival to consultants, regardless of the level of scrubbed consultant supervision (supervised: adjusted HR = 0.99, 95% CI [0.87, 1.14]; p = 0.94; unsupervised: adjusted HR = 1.03, 95% CI [0.87, 1.22]; p = 0.74). Limitations of this study relate to its observational design and include: the potential for nonrandom allocation of cases by consultants to trainees; residual confounding; and the use of the binary variable "surgeon grade," which does not capture variations in the level of experience between trainees. CONCLUSIONS: This nationwide study of UKRs with over 16 years' follow up demonstrates that trainees within the current training system in England and Wales achieve comparable all-cause implant survival to consultants. These findings support the current methods by which surgeons in England and Wales are trained to perform UKR.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Sistema de Registros , Reoperación , Humanos , Reoperación/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/educación , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Gales , Inglaterra , Cirujanos/educación , Competencia Clínica , Factores de Riesgo , Osteoartritis de la Rodilla/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: To investigate the relationship between preoperative low serum albumin and perioperative blood transfusion in patients undergoing total joint arthroplasty (TJA). METHODS: We enrolled 2,772 TJA patients from our hospital between January 1, 2017, and January 1, 2022. Clinical data were extracted from electronic medical records, including patient ID, sex, BMI (Body Mass Index), age, and diagnoses. Receiver operating characteristic curves were constructed to establish thresholds for serum albumin levels categorization. Propensity score matching (PSM) was developed with preoperative serum albumin as the dependent variable and perioperative blood transfusion-related factors as covariates, including BMI grade, age grade, sex, diagnosis, hypertension, diabetes, coronary heart disease, chronic obstructive pulmonary disease, chronic bronchitis, cerebral infarction, major surgeries within the last 12 months, renal failure, cancer, depression, corticosteroid use, smoking, drinking, and blood type. The low serum albumin group was matched with the normal albumin group at a 1:2 ratio, employing a caliper value of 0.2. Binary logistic regression was employed to analyze the outcomes. RESULTS: An under the curve of 0.601 was discovered, indicating a cutoff value of 37.3 g/L. Following PSM, 892 cases were successfully paired in the low serum (< 37.3 g/L) albumin group, and 1,401 cases were matched in the normal serum albumin (≥ 37.3 g/L) group. Binary logistic regression in TJA patients showed that the albumin OR was 0.911 with 95%CI 0.888-0.935, P < 0.001. Relative to the preoperative normal serum albumin group, TJA patients in the low serum albumin group experienced a 1.83-fold increase in perioperative blood transfusion rates (95% CI 1.50-2.23, P < 0.001). Compared to the normal serum albumin group, perioperative blood transfusion rates for TJA patients with serum albumin levels of 30-37.3 g/L, 25-30 g/L, and ≤ 25 g/L increased by 1.63 (95% CI 1.37-1.99, P < 0.001), 5.4 (95% CI 3.08-9.50, P < 0.001), and 6.43 times (95% CI 1.80-22.96, P = 0.004), respectively. CONCLUSION: In TJA patients, preoperative low serum albumin levels have been found to be associated with an increased risk of perioperative blood transfusion. Furthermore, it has been observed that the lower the preoperative serum albumin level is, the higher the risk of perioperative blood transfusion. TRIAL REGISTRATION: 28/12/2021, Chinese Clinical Trial Registry, ChiCRT2100054844.
Asunto(s)
Transfusión Sanguínea , Puntaje de Propensión , Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Transfusión Sanguínea/estadística & datos numéricos , Transfusión Sanguínea/tendencias , Estudios Retrospectivos , Periodo Preoperatorio , Albúmina Sérica Humana/análisis , Artroplastia de Reemplazo de Cadera/efectos adversos , Factores de Riesgo , Albúmina Sérica/análisis , Albúmina Sérica/metabolismo , Artroplastia de Reemplazo de Rodilla/efectos adversos , Pérdida de Sangre Quirúrgica/prevención & controlRESUMEN
INTRODUCTION: In the evaluation of an internal analysis of data on the increased effort for nursing during rehabilitation of patients with amputations in the Baumrainklinik of the HELIOS Rehabilitation Center Bad Berleberg, the number of patients with transfemoral amputations (TFA) due to uncontrollable multiple infections after implantation of a total knee endoprosthesis (total knee arthroplasty, TKA) was clearly emphasized. OBJECTIVE: This article discusses the results of a retrospective, patient-controlled trial (PCT) and compares these with the data of the German Endoprosthesis Registry (EPRD). The study concentrated on patients who were admitted to rehabilitation after a TFA due to an uncontrollable infection after implantation of a knee TKA. The primary aims were the identification of patients who developed an uncontrollable infection after TKA with subsequent TFA and the comparison with national and international revision and amputation rates after TKA. METHOD: An analysis of the medical history questionnaire was carried out for all 787 patients with amputation of the lower extremities who underwent rehabilitation in the time period from 1st January 2007 to 31st December 2015. The patient records were systematically analyzed based on the standardized documentation methods of the medical and nursing personnel using the Barthel index, the activity/function classes, phantom pain and length of stay, including demography, infection history and insurance company. RESULTS: The analysis showed that 10 patients, 2.29% of all TFA, suffered the loss of a lower extremity due to an uncontrollable TKA infection. The revision rate 3 years after primary TKA in Germany is 3.0% (EPRD annual report 2023), whereas values of 1-4% are given in the international literature (status 2020). In the patient group of the EPRD, in 2022 revision surgery was necessary due to an infection in 15.0% of the cases. The current statistics of the EPRD (annual report 2023) show that 3 years after the initial revision surgery due to an infected TKA another revision was necessary in 23.5-30% of cases. CONCLUSION: These numbers are alarming and should be critically evaluated and monitored. The future aim is to identify the causes of infections, systematic errors in the TKA and the pathogens that lead to infections after TKA and to correlate the associations.
Asunto(s)
Amputación Quirúrgica , Artroplastia de Reemplazo de Rodilla , Infecciones Relacionadas con Prótesis , Humanos , Amputación Quirúrgica/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Masculino , Alemania/epidemiología , Anciano , Femenino , Estudios Retrospectivos , Infecciones Relacionadas con Prótesis/etiología , Persona de Mediana Edad , Prótesis de la Rodilla/efectos adversos , Anciano de 80 o más Años , Reoperación , Sistema de Registros , Fémur/cirugíaRESUMEN
This prospective bi-center study aimed to analyze the outcomes of primary total knee arthroplasty using the Stemmable Tibia Attune system. A total of 100 patients who underwent primary total knee arthroplasty with Stemmable Tibia from January 2019 to December 2021 were enrolled in the study. Radiological outcomes (hip-knee-ankle axis and medial proximal tibial angle) were assessed preoperatively and postoperatively. Clinical outcomes (visual analog scale score, Hospital for Special Surgery score, Knee Society function score, Knee Society knee score, flexion contracture, further flexion, and range of motion) were analyzed preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Complications (periprosthetic joint infection and aseptic loosening) were examined. The hip-knee-ankle axis decreased (preoperative: 9.5° ± 6.3°, postoperative: 1.1° ± 2.7°), whereas the medial proximal tibial angle increased (preoperative: 84.6° ± 4.1°, postoperative: 89.8° ± 1.9°). The visual analog scale score, Hospital for Special Surgery score, Knee Society knee score, and Knee Society function score increased postoperatively. The Knee Society knee score indicated above good outcomes (100.0% and 99.0% at 1 and 2 years postoperatively, respectively). The Knee Society function score also showed above good results (98.0% and 93.0% at 1 and 2 years postoperatively, respectively). The range of motion significantly improved (p < 0.001): flexion contracture decreased from 9.10° ± 7.23° to 2.15° ± 2.87°, whereas further flexion increased from 136.05° ± 14.78° to 139.80° ± 10.02°. One patient developed periprosthetic joint infection; no early loosening was observed. In conclusion, Attune primary total knee arthroplasty with Stemmable Tibia not only is safe and effective but also leads to radiological and clinical improvements.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Rango del Movimiento Articular , Tibia , Humanos , Artroplastia de Reemplazo de Rodilla/métodos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Masculino , Femenino , Anciano , Estudios Prospectivos , Persona de Mediana Edad , Estudios de Seguimiento , Tibia/cirugía , Tibia/diagnóstico por imagen , Resultado del Tratamiento , Articulación de la Rodilla/cirugía , Articulación de la Rodilla/diagnóstico por imagen , Prótesis de la RodillaRESUMEN
RATIONALE: Periprosthetic fractures (PPF) are rare complications of total knee arthroplasty (TKA). The most common PPF after TKA is supracondylar femoral fracture, which is a relatively rare complication that is usually associated with high-energy trauma, with a reported incidence ranging from 0.4 to 1.7% according to the AOANJRR. However, in TKA patients, it is rarer that the stress fracture around the tibial prosthesis occurs due to changes in the lower limb force line, increasing weight-bearing, and changes in walking gait. PATIENT CONCERNS: A 68-year-old woman visited our hospital with "both knees had aggravated pain and deformity for 8 years." TKA was performed first on the left knee and the patient was discharged within 1 week. Three months later, the patient complained of pain in the upper middle 1/3 part of the medial tibia for 2 weeks, which gradually worsened and affected weight-bearing. DIAGNOSES: Physical examination showed that the left knee joint presented varus deformity, and the right valgus deformity, which diagnosed as osteoarthritis of both knees and was so-called "blownknee". The disease was initially diagnosed as osteoarthritis of both knees on first admission and PPF of the tibia in second. INTERVENTIONS: Three operations were performed on this patient. The first was TKA of the left knee, the second was open reduction and internal fixation of the PPF of the tibia 3 months after the first operation, and the third was TKA of the right knee. OUTCOMES: Until now, the patient has had no recurrent PPF, and the fracture is healing from the last X-ray. LESSONS: Clinicians should be aware of the possibility of PPF after TKA, especially in such patients, the most preferred surgical treatment method was open reduction and internal fixation of fractures using locking plates, and if the PPF with loosened implants, Revision TKA, or megaprosthesis was the better choice.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Fracturas por Estrés , Fracturas de la Tibia , Humanos , Femenino , Artroplastia de Reemplazo de Rodilla/efectos adversos , Anciano , Fracturas por Estrés/etiología , Fracturas por Estrés/cirugía , Fracturas de la Tibia/cirugía , Fracturas de la Tibia/etiología , Fracturas Periprotésicas/etiología , Fracturas Periprotésicas/cirugía , Osteoartritis de la Rodilla/cirugíaRESUMEN
BACKGROUND AND PURPOSE: Chronic postsurgical pain after total knee arthroplasty (TKA) is frequent and may be reduced by pain neuroscience education (PNE), teaching people about pain from a neurobiological perspective. This study investigated primarily the effectiveness of 2 individual sessions of PNE versus usual care on pain levels 3 months postoperatively in patients undergoing TKA. Secondary outcomes were physical functioning, stiffness, health-related quality of life, pain catastrophizing, attention to pain, and levels of anxiety and depression. METHODS: A prospective single-center, parallel-group randomized controlled trial was undertaken including patients aged 18 years or older scheduled for primary TKA. 68 patients were randomly assigned to PNE or usual care. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score 3 months postoperatively. Outcomes were measured preoperatively, at 2 weeks (acute phase), and at 3 and 12 months postoperatively. RESULTS: We found no statistically significant difference (0.4 points; 95% confidence interval [CI] -1.7 to 2.4) in WOMAC pain scores 3 months after TKA between the PNE and control group. We found a statistically significant difference between the 2 groups for attention to pain at 3 months in favor of PNE (P = 0.02). CONCLUSION: This RCT showed that PNE was not superior to usual care in terms of reducing pain at 3 months after TKA. Attention to pain, as a secondary outcome, was significantly lower in the PNE group compared with usual care. Other secondary outcome measures showed no significant differences.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Dolor Crónico , Dimensión del Dolor , Dolor Postoperatorio , Educación del Paciente como Asunto , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/rehabilitación , Femenino , Masculino , Dolor Postoperatorio/etiología , Anciano , Estudios Prospectivos , Persona de Mediana Edad , Educación del Paciente como Asunto/métodos , Dolor Crónico/etiología , Calidad de Vida , Osteoartritis de la Rodilla/cirugía , Neurociencias/educación , Catastrofización , Resultado del TratamientoRESUMEN
BACKGROUND: Deep vein thrombosis (DVT) of lower extremity is a common complications after total knee arthroplasty (TKA). The purpose of this study was to evaluate the risk factors for DVT after TKA and analyze the expression of miR-199b-5p and nitric oxide (NO) before and after TKA, as well as their predictive value for DVT. METHODS: Basic clinical information of 121 patients with TKA was analyzed retrospectively. RT-qPCR was used to detect the relative expression level of miR-199b-5p in patients before and after TKA treatment. Based on the occurrence of DVT, patients were divided into DVT and non-DVT groups. Logistic regression analysis evaluated the risk factors of DVT. The receiver operating characteristic (ROC) curve assessed the predictive value of postoperative miR-199b-5p level, preoperative NO level, and their combination in DVT. The target genes of miR-199b-5p and their functions were predicted and annotated using bioinformatics analysis. RESULTS: The level of miR-199b-5p after TKA was upregulated compared with that before TKA (P < 0.001). DVT occurred in 20 of 121 patients after TKA, with an incidence of 16.53%. Multivariate analysis showed that age, family history of DVT, decrease of NO and increase of miR-199b-5p were risk factors for DVT after TKA (P < 0.05). The ROC curve showed that both miR-199b-5p and NO had certain diagnostic value for DVT, but the combination of miR-199b-5p and NO had the highest diagnostic accuracy (P < 0.001). CONCLUSION: This study showed that the expression of miR-199b-5p was up-regulated after TKA, and miR-199b-5p levels were higher in DVT patients than in non-DVT patients. miR-199b-5p combined with NO is of great value in the diagnosis of DVT after TKA.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , MicroARNs , Óxido Nítrico , Valor Predictivo de las Pruebas , Trombosis de la Vena , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Masculino , Femenino , MicroARNs/genética , Óxido Nítrico/metabolismo , Anciano , Persona de Mediana Edad , Trombosis de la Vena/etiología , Trombosis de la Vena/genética , Estudios Retrospectivos , Complicaciones Posoperatorias/etiología , Factores de RiesgoRESUMEN
BACKGROUND: Postoperative delirium (POD) is a common surgical complication. However, the incidence and risk factors associated with postoperative delirium after revision total knee arthroplasty (rTKA) have not been comprehensively explored through extensive national databases. METHODS: Utilizing the National Inpatient Sample (NIS), the largest comprehensive U.S. hospital healthcare database, we undertook a retrospective investigation involving 127,400 patients who underwent rTKA between 2010 and 2019. We assessed various aspects, including patient demographics, hospital characteristics, pre-existing medical conditions, and perioperative complications. RESULTS: The overall incidence of postoperative delirium (POD) in patients undergoing rTKA between 2010 and 2019 was 0.97%. The highest incidence rate of 1.31% was recorded in 2013. Notably, this patient cohort demonstrated advanced age, increased burden of co-morbidities, prolonged hospital stays, increased hospitalization costs, and elevated in-hospital mortality rates (P < 0.001). Moreover, non-elective admissions, non-private insurance payments, and a preference for teaching hospitals were commonly observed among these patients. During their hospitalization, individuals who developed delirium subsequent to rTKA were more prone to experiencing certain perioperative complications. These complications encompassed medical issues like acute myocardial infarction, continuous invasive mechanical ventilation, postoperative shock, sepsis, stroke and other medical problems. Additionally, surgical complications including hemorrhage / seroma / hematoma, irrigation and debridement, prosthetic joint infection, periprosthetic fracture, and wound dehiscence / nonunion were noted. Several risk factors were found to be linked with the development of POD. These included advanced age (≥ 75 years), alcohol abuse, coagulation disorders, congestive heart failure, depression, fluid and electrolyte imbalances, and more. Conversely, female sex, having private insurance, and undergoing elective hospitalization emerged as protective factors against POD. CONCLUSION: Our findings suggest that the general prevalence of POD in rTKA is relatively low according to NIS. There was a significant connection between the POD of rTKA and advanced age, prolonged length of stay (LOS), more in-patients' costs, higher in-hospital mortality rate, increased comorbidities, postoperative medical complications and postoperative surgical complications. This study helps to understand the risk factors associated with POD to improve poor outcomes.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Bases de Datos Factuales , Delirio , Complicaciones Posoperatorias , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Masculino , Femenino , Estudios Retrospectivos , Factores de Riesgo , Anciano , Persona de Mediana Edad , Incidencia , Estados Unidos/epidemiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Delirio/epidemiología , Delirio/etiología , Reoperación/estadística & datos numéricos , Anciano de 80 o más Años , Pacientes Internos , Adulto , Tiempo de Internación , Mortalidad HospitalariaRESUMEN
INTRODUCTION: Venous thromboembolism (VTE) is a major concern following total knee arthroplasty (TKA). The optimal pharmacological prophylaxis remains, however, controversial. The present investigation compared several non-vitamin K antagonist oral anticoagulants commonly employed as VTE prophylaxis following TKA. A Bayesian network meta-analysis was conducted to compare apixaban, aspirin, dabigatran, edoxaban, enoxaparin, fondaparinux, and rivaroxaban. The outcomes of interest were to compare the rate of deep venous thrombosis (DVT), pulmonary embolism (PE), and major and minor haemorrhages. METHODS: This study was conducted according to the PRISMA Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-Analyses of Health Care Interventions. In March 2024, PubMed, Web of Science, and Google Scholar were accessed with no time constraints. All randomised controlled trials (RCTs) comparing two or more drugs for the prevention of VTE following TKA were considered for inclusion. RESULTS: Data from 29,678 patients were collected. Of them, 67% (19,884 of 29,678 patients) were women. The mean age of the patients was 66.8 ± 2.8 years, and the mean BMI was 29.2 ± 1.5 kg/m2. There was comparability in age, sex, and BMI at baseline. Apixaban 5 mg, dabigatran 220 mg, and rivaroxaban 10 mg were the most effective in reducing the rate of DVT. Apixaban 5 mg, enoxaparin 60 mg, and rivaroxaban 40 mg were the most effective in reducing the rate of PE. Apixaban 5 mg, rivaroxaban 10 mg, and apixaban 10 mg were associated with the lowest rate of major haemorrhages. Apixaban 5 mg and 20 mg, and dabigatran 220 mg were associated with the lowest rate of minor haemorrhages. CONCLUSION: Administration of apixaban 5 mg demonstrated the best balance between VTE prevention and haemorrhage control following TKA. LEVEL OF EVIDENCE: Level I, network meta-analysis of RCTs.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Teorema de Bayes , Metaanálisis en Red , Tromboembolia Venosa , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/etiología , Rivaroxabán/uso terapéutico , Rivaroxabán/administración & dosificación , Piridonas/administración & dosificación , Piridonas/uso terapéutico , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Dabigatrán/uso terapéutico , Dabigatrán/administración & dosificación , Pirazoles/uso terapéutico , Aspirina/uso terapéutico , Aspirina/administración & dosificación , Fibrinolíticos/uso terapéutico , Fibrinolíticos/administración & dosificación , Embolia Pulmonar/prevención & control , Embolia Pulmonar/etiología , Enoxaparina/administración & dosificación , Enoxaparina/uso terapéutico , Hemorragia/inducido químicamente , Femenino , Fondaparinux/uso terapéutico , Piridinas , TiazolesRESUMEN
BACKGROUND: The use of a tibial stem for large deformities (> 10°) would reduce the incidence of pain. The aim of this study was to compare the effect of tibial stem on postoperative pain and aseptic loosening at the tibia in patients with a preoperative deformity > 10° in the frontal plane at 2 years follow-up. METHODS: This was a retrospective single-center case-control study. Ninety-eight patients with deformities greater than 10° in the frontal plane and a BMI > 30 kg/m2 who had undergone posterior-stabilized (PS) total knee arthroplasty (TKA) with a tibial stem were matched using a propensity score to 98 patients who had undergone PS TKA without a tibial stem. The primary endpoint was the pain rate at 2 years. The secondary endpoints were the rate of aseptic loosening of the tibia at 2 years post-operatively. RESULTS: A significant difference was found in the rate of postoperative pain at 2 years. It was higher in the group without tibial stem compared with the group with tibial stem (41.8% vs 17.3%, p = 0.0003). In the group without tibial stem, 24.4% of pain was mild, 61% moderate and no severe pain. In the tibial stem group, 47.1% of pain was mild, 41.2% moderate and no severe pain. A radiolucent line (RLL) was present at 2 years in 26.5% of prostheses in the without tibial stem group and in 9.2% of prostheses in the tibial stem group (p = 0.002). There was no difference between the two groups in terms of aseptic loosening. CONCLUSION: The use of a tibial stem in primary TKA in patients with frontal deformities greater than 10° reduces postoperative pain and the presence of radiolucent lines.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Prótesis de la Rodilla , Dolor Postoperatorio , Falla de Prótesis , Humanos , Artroplastia de Reemplazo de Rodilla/métodos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Femenino , Masculino , Estudios Retrospectivos , Anciano , Estudios de Casos y Controles , Persona de Mediana Edad , Prótesis de la Rodilla/efectos adversos , Tibia/cirugía , Diseño de Prótesis , Osteoartritis de la Rodilla/cirugíaRESUMEN
Aims: We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty. Methods: A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were aspirin (< 325 mg and ≥ 325 mg daily), enoxaparin, dalteparin, fondaparinux, unfractionated heparin, warfarin, rivaroxaban, apixaban, and dabigatran. The primary efficacy outcome of interest was the risk of VTE, whereas the primary safety outcomes of interest were the risk of major bleeding events (MBE) and wound complications (WC). VTE was defined as the confirmed diagnosis of any deep vein thrombosis and/or pulmonary embolism. Network meta-analysis combining direct and indirect evidence was performed. Cluster rank analysis using the surface under cumulative ranking (SUCRA) was applied to compare each intervention group, weighing safety and efficacy outcomes. Results: Of 86 studies eligible studies, cluster rank analysis showed that aspirin < 325 mg daily (SUCRA-VTE 89.3%; SUCRA-MBE 75.3%; SUCRA-WC 71.1%), enoxaparin (SUCRA-VTE 55.7%; SUCRA-MBE 49.8%; SUCRA-WC 45.2%), and dabigatran (SUCRA-VTE 44.9%; SUCRA-MBE 52.0%; SUCRA-WC 41.9%) have an overall satisfactory efficacy and safety profile. Conclusion: We recommend the use of either aspirin < 325 mg daily, enoxaparin, or dabigatran for VTE prophylaxis following hip and knee arthroplasty.
Asunto(s)
Anticoagulantes , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Tromboembolia Venosa , Humanos , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Dabigatrán/uso terapéutico , Dabigatrán/efectos adversos , Complicaciones Posoperatorias/prevención & control , Resultado del Tratamiento , Tromboembolia Venosa/prevención & control , Tromboembolia Venosa/etiología , Metaanálisis en RedRESUMEN
Extensor mechanism (EM) disruption after total knee arthroplasty (TKA) is devastating, especially in cases of re-rupture. A 67-year-old man with diabetes had patellar tendon rupture after revision TKA and then had migration of the bone block after Achilles tendon allograft with bone block (ATBB) augmentation with cerclage. A third reconstruction was performed with open reduction and internal fixation and high-strength braided suture augmentation. Five months postoperatively, the patient had regained full range of motion with intact EM and hardware. The risk of re-rupture is high in ATBB, and the primary issues in this case were nonunion and tendinous compromise. A construct that encompasses compression and buttressing of the bone block with tendon augmentation potentially addresses the risks of recurrent EM rupture in more complex cases. [Orthopedics. 2024;47(5):e273-e276.].
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Reoperación , Humanos , Masculino , Anciano , Artroplastia de Reemplazo de Rodilla/efectos adversos , Traumatismos de los Tendones/cirugía , Ligamento Rotuliano/cirugía , Ligamento Rotuliano/lesiones , Tendón Calcáneo/cirugía , Tendón Calcáneo/lesiones , Complicaciones Posoperatorias/cirugía , Complicaciones Posoperatorias/etiologíaRESUMEN
INTRODUCTION: Several risk factors are associated with acute venous thromboembolism (VTE) after total joint arthroplasty (TJA). However, there is a lack of literature regarding the cumulative impact of multiple risk factors. To address this gap, we utilized the PearlDiver database, an insurance billing claims database containing de-identified data from 91 million orthopedic patients. METHODS: The PearlDiver database was queried for records of patients who underwent total hip and knee arthroplasty from 2010 to 2019 using ICD-10 and CPT codes. Twelve persistent and two transient risk factors were analyzed for their association with the occurrence of acute VTE within three months after surgery. Univariate and logistic regression analyses with odds ratios (ORs) and confidence intervals (CIs) were conducted to determine the odds associated with each risk factor and the impact of multiple concurrent risk factors. RESULTS: A total of 988,675 patients who underwent hip and knee arthroplasty met the inclusion criteria, of whom 1.5% developed acute VTE after three months. The prevalence of VTE risk factors ranged from 0.2 to 38.6%. Individual, persistent risk factors demonstrated 14-84% increased odds of VTE compared to a 1.2% increase for a transient risk factor (acute myocardial infarction). Three or more persistent risk factors were associated with a higher risk of VTE. CONCLUSION AND RELEVANCE: Persistent risk factors were associated with a higher incidence of postoperative VTE than transient risk factors. An incremental increase in risk was noted if three or more persistent risk factors were present.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Tromboembolia Venosa , Humanos , Tromboembolia Venosa/etiología , Tromboembolia Venosa/epidemiología , Factores de Riesgo , Masculino , Femenino , Persona de Mediana Edad , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Cadera/efectos adversos , Anciano , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Estudios de Cohortes , Bases de Datos Factuales , Adulto , Enfermedad AgudaRESUMEN
OBJECTIVE: Adductor canal block (ACB) is widely performed for postoperative analgesia for total knee arthroplasty (TKA). The aim of this study is to compare surgeon-assisted and anesthesiologist-assisted (ultrasound-guided) adductor blocks in terms of postoperative analgesic efficacy. METHODS: This study was designed as a double-blind, prospective and randomized trial. A total of 240 participants were randomly allocated to three groups: one where the surgeon performed the adductor canal block (ACBs), another where it was conducted by an anesthetist with ultrasound guidance (ACBa), and a third group without the adductor block. The follow-up management after the Total Knee Arthroplasty (TKA) procedure occurred on the first, third, and tenth days, as well as the twelfth week. Outcome measures comprised pain assessment using the Visual Analog Scale (VAS) and monitoring opioid analgesic consumption. RESULTS: No significant differences in demographic profiles were observed between the groups. Groups ACBa and ACBs exhibited significantly lower VAS scores compared to the control group at both 3 and 12 h after surgery, with group ACBa showing the lowest VAS scores among all groups. However, at 1 day, 3 days, 10 days and 12 weeks after surgery, there was no significant difference in VAS scores between the ACBa and ACBs groups. On the first three days, the ACBa group had the lowest opioid consumption and the lowest total opioid consumption. The differences in VAS scores between the groups began to decrease on the first day after surgery. CONCLUSION: The adductor canal block (ACB) has been demonstrated to be an effective method of reducing pain in patients undergoing total knee replacement (TKR) in the postoperative period. Nevertheless, despite the pronounced impact that ACB performed by an anesthesiologist under ultrasound guidance has on VAS scores according to intraoperative ACB by surgeons, its effect on clinical outcomes has not been demonstrated. TRIAL REGISTRATIONS: This study was retrospectively registered with the Clinical Trials Registry Platform on July 31, 2024 (NCT06533085).
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Bloqueo Nervioso , Dimensión del Dolor , Dolor Postoperatorio , Ultrasonografía Intervencional , Humanos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Dolor Postoperatorio/prevención & control , Dolor Postoperatorio/etiología , Dolor Postoperatorio/diagnóstico , Femenino , Masculino , Bloqueo Nervioso/métodos , Estudios Prospectivos , Método Doble Ciego , Ultrasonografía Intervencional/métodos , Anciano , Persona de Mediana Edad , Manejo del Dolor/métodos , Resultado del Tratamiento , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéuticoRESUMEN
OBJECTIVES: This study aimed to investigate the relationship between the severity of preoperative valgus deformity and clinical outcomes of neutrally aligned total knee arthroplasty (TKA). PATIENTS AND METHODS: A total of 376 knees with valgus deformity who underwent TKA from January 2006 to March 2014 were retrospectively screened, and 287 knees (242 patients; 32 males, 210 females; mean age: 64.5±8.8 years; range, 35 to 83 years) aligned neutrally after the operation were included. Patients were divided into four groups based on the preoperative hip-knee-ankle (HKA): mild (0°< HKA ≤5°, n=94), moderate (5°< HKA ≤10°, n=74), severe (10°< HKA ≤15°, n=75), and very severe (HKA >15°, n=44) groups. Range of motion (ROM), Knee Society Score (KSS), Visual Analog Scale (VAS) dynamic pain scores, and Forgotten Joint Score (FJS) were evaluated. Mechanical failures were recorded to assess prosthesis survival. A survival rate analysis was performed using Kaplan-Meier survival analysis. RESULTS: The degree of preoperative valgus deformity did not have a significant impact on the postoperative ROM, KSS, VAS dynamic pain scores, or FJS at the last follow-up. There were no significant differences in cumulative survival rates of neutrally aligned TKAs at 10 years between the four groups (p=0.513). CONCLUSION: The severity of preoperative valgus deformity did not affect the clinical outcomes of neutrally aligned TKAs in the minimum five-year follow-up. Additionally, it did not impact the survival rates of neutrally aligned TKAs over 10 years.