Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. Single-dose periarticular steroid infiltration for pain management in total knee arthroplasty: a prospective, double-blind, randomised controlled trial. Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT Effect of preoperative exercise on measures of functional status in men and women undergoing total hip and knee arthroplasty. An effective method to reduce ischemia time during total knee arthroplasty. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: A randomized clinical trial The reduction in blood loss with intra-articular injection of tranexamic acid in unilateral total knee arthroplasty without operative drains: a randomized controlled trial Auricular acupressure for analgesia in perioperative period of total knee arthroplasty. Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up Local infiltration anesthesia with steroids in total knee arthroplasty: A systematic review of randomized control trials. Combined Administration of Systemic and Topical Tranexamic Acid for Total Knee Arthroplasty: Can It Be a Better Regimen and Yet Safe? A Randomized Controlled Trial. Effect of weekend physical therapy treatment on postoperative length of stay following total hip and total knee arthroplasty. Efficacy and safety evaluation of intra-articular injection of tranexamic acid in total knee arthroplasty operation with temporarily drainage close. Perioperative risk factors for deep vein thrombosis after total hip arthroplasty or total knee arthroplasty. Multicenter randomized controlled trial comparing early versus late aquatic therapy after total hip or knee arthroplasty. The Feasibility and Perioperative Complications of Outpatient Knee Arthroplasty Patellar eversion does not adversely affect quadriceps recovery following total knee arthroplasty.
In this prospect i ve r and omized study , patients undergoing total hip ( THA ) or knee arthroplasty ( TKA ) were r and omized to either a study group receiving periarticular injections or a control group receiving patient-controlled analgesia with or without femoral nerve block ( TKA patients ) . All patients received a comprehensive multimodal perioperative protocol .  Pain , recovery of functional milestones , and overall satisfaction were assessed . The THA study group demonstrated significantly lower average pain scores and higher overall satisfaction than the control group . There was no significant difference in pain scores between the study and control groups in the TKA cohort . Both study groups demonstrated lower narcotic usage and side effects as well as improved early functional recovery . Periarticular injection with a multimodal protocol was shown to safely provide excellent pain control and functional recovery and can be substituted for conventional pain control modalities INTRODUCTION Post total knee replacement pain control using parenteral opioids results in significant side effects like nausea and vomiting . Periarticular injections are used to control pain without these side effects . This study aim ed to evaluate the safety and efficacy of periarticular steroid injection in patients undergoing total knee arthroplasty , as well as assess the patient 's functional outcomes over a period of two years . METHODS A total of 100 patients who underwent total knee arthroplasty were r and omised into two groups . The treatment group received periarticular infiltration with triamcinolone acetonide , bupivacaine and epinephrine . The control group received only bupivacaine and epinephrine . The postoperative analgesic regime was st and ardised for all patients . The immediate postoperative outcomes evaluated included pain score , morphine consumption , time to ambulation , straight leg raise , range of motion and duration of hospital stay . Longer-term outcomes were assessed at 1 , 3 , 6 and 24 months using the SF-36 question naire and Oxford Knee Score . RESULTS Patients in the treatment group had significantly lower pain scores , reduced morphine consumption and earlier discharge . They also had better range of knee motion and were able to regain muscular strength earlier . There was no increase in major complications such as infection or tendon rupture in the treatment group . There was no difference between the groups with regard to the medium-term outcomes of up to two years . CONCLUSION This modality of pain control is safe and efficacious for post total knee replacement pain control Background The main goal of physical therapy treatment ( PT ) in the clinical stage following total knee arthroplasty ( TKA ) is to prepare patients for discharge from the hospital as soon as possible after their operation . Although aggressive rehabilitation is believed to be important , evidence of effects of different exercise programmes following TKA is limited . This led to the question whether the intensity of PT ( once versus twice daily ) following TKA affects short-term recovery , measured as range of motion . Methods A r and omised controlled trial compared an exercise regimen of two sessions per day with a similar programme administered once daily . Primary outcome measure was ROM . Results At the time of hospital discharge , there was no difference between the experimental and control groups in range of motion . Conclusion This study shows that in our setting twice daily PT sessions do not produce different results as daily PT sessions . It may be question ed whether multiple daily therapy sessions are needed as an in-hospital PT regimen in OA total knee patients OBJECTIVE To evaluate the effect of a short preoperative exercise intervention on the functional status , pain , and muscle strength of patients before and after total joint arthroplasty . METHODS A total of 108 men and women scheduled for total hip arthroplasty ( THA ) or total knee arthroplasty ( TKA ) were r and omized to a 6-week exercise or education ( control ) intervention immediately prior to surgery . We assessed outcomes through question naires and performance measures . Analyses examined differences between groups over the preoperative and immediate postoperative periods and at 8 and 26 weeks postsurgery . RESULTS Among THA patients , the exercise intervention was associated with improvements in preoperative Western Ontario and McMaster Universities Osteoarthritis Index function score ( improvement of 2.2 in exercisers versus decline of 3.9 in controls ; P = 0.02 ) and Short Form 36 physical function score ( decline of 0.4 in exercisers versus decline of 14.3 in controls ; P = 0.003 ) . No significant differences were seen in TKA patients . Exercise participation increased muscle strength preoperatively ( 18 % in THA patients and 20 % in TKA patients ) , whereas the control patients had essentially no change in strength ( P > 0.05 for exercise versus education in both THA and TKA groups ) . Exercise participation prior to total joint arthroplasty substantially reduced the risk of discharge to a rehabilitation facility in THA and TKA patients ( adjusted odds ratio 0.27 , 95 % confidence interval 0.074 - 0.998 ) . The intervention had no effects on outcomes 8 and 26 weeks postoperatively . CONCLUSION A 6-week presurgical exercise program can safely improve preoperative functional status and muscle strength levels in persons undergoing THA . Additionally , exercise participation prior to total joint arthroplasty dramatically reduces the odds of inpatient rehabilitation BACKGROUND / PURPOSE Because of controversy regarding timing of tourniquet release during total knee arthroplasty ( TKA ) , a closed arthrotomy as a tamponade for effective hemostasis was used to save ischemia time . The study was to verify the safety and efficacy on clinical issues . METHODS A prospect i ve cohort study was conducted on 72 consecutive unilateral primary TKAs . They were divided into two groups according to different timing of tourniquet release . The study group was composed of 36 index procedures with an intra-operative release after a tight arthrotomy closure ; while the remaining 36 TKAs with a tourniquet application throughout the procedure comprised the comparative group . In all operations , no drain was used to augment the intra-articular tamponade . RESULTS In the study group , the tourniquet time was significantly shorter ( p<0.001 ) , and thus ischemic duration and perioperative blood loss were reduced . The postoperative course was similar on the basis of analgesics consumption and inpatient stay , but better earlier functional recovery as well as subjective performance was observed at early postoperative follow-ups . CONCLUSIONS The results suggest that a closed tamponade with arthrotomy closure and drainage avoidance is an effective hemostasis to reduce ischemia time during TKAs Background Postoperative pain  after total knee arthroplasty ( TKA ) can be difficult to manage and may delay recovery . Recent studies have suggested that periarticular infiltration with local anesthetics may improve outcome . Methods 80 patients undergoing TKA under spinal anesthesia were r and omized to receive continuous femoral nerve block ( group F ) or peri- and intraarticular infiltration and injection ( group I ) . Group I received a solution of 300 mg ropivacaine , 30 mg ketorolac , and 0.5 mg epinephrine by infiltration of the knee at the end of surgery , and 2 postoperative injections of these substances through an intraarticular catheter . Results More patients in group I than in group F could walk < 3 m on the first postoperative day ( 29/39 vs. 7/37 , p < 0.001 ) . Group I also had significantly lower pain scores during activity and lower consumption of opioids on the first postoperative day . No differences between groups were seen regarding side effects or length of stay . Interpretation Peri- and intraarticular application of analgesics by infiltration and bolus injections can improve early analgesia and mobilization for patients undergoing TKA . Further studies of optimal drugs , dosage , and duration of this treatment are warranted Abstract The objective of this r and omized controlled trial was to evaluate the efficacy and safety of intra-articular injections of tranexamic acid ( TXA ) on perioperative blood loss and transfusion in primary unilateral total knee arthroplasty ( TKA ) without drainage . Primary TKA was performed on a total of 80 patients ( 80 knees ) affected to various degrees by knee osteoarthritis . The patients were r and omized to receive 500 mg of TXA in 20 mL of normal saline solution ( n = 40 ) or an equivalent volume of normal saline solution ( n = 40 ) , applied into the joint for 5 min at the end of surgery . Data on routine blood examination , blood loss and blood transfusion after TKA were compared between the two groups . The results showed no significant difference between the two groups in intra-operative blood loss ( P = 0.136 ) . The mean postoperative visible blood loss , hidden blood loss and transfusion requests were significantly different between the two groups ( P < 0.05 ) . The values of postoperative hemoglobin and hematocrit were lower in the control group compared with those in the treatment group ( P < 0.05 ) . No deep vein thrombosis was detected through Doppler ultrasound examination . Three hour postoperative D-dimer in the control group was higher than the treatment group ( P = 0.02 ) . There was no statistically significant difference between the coagulation indicators and range of motion in the two groups . We conclude that intra-articular TXA in patients undergoing unilateral TKA could significantly reduce postoperative blood loss and blood transfusion and avoid perioperative anemia-related complications without increased risk of venous thrombosis . Level of evidence Level I. Therapeutic study OBJECTIVE We examined whether auricular acupressure ( AA ) can alleviate postoperative pain and decrease narcotic consumption and its adverse effects for osteoarthritis patients after total knee arthroplasty ( TKA ) . DESIGN A prospect i ve , r and omized , sham control trial comparing AA and a sham control . SETTING Department of Orthopedics , the first Hospital affiliated to Zhejiang University of Traditional Chinese Medicine , Hangzhou , China . SUBJECTS Ninety patients with degenerative osteoarthritis undergoing TKA . INTERVENTIONS The AA group received true AA by embedding vaccaria seeds at four specific AA points ( knee joint , shenmen , subcortex , sympathesis ) ipsilateral to the surgery site , while the control group received four nonacupuncture points on the auricular helix . OUTCOME MEASURES Visual analog scale ( VAS ) , the consumption of analgesic via patient-controlled analgesia , the incidence of analgesia-related adverse effects , Hospital for Special Surgery scores ( HSS ) , and range of motion ( ROM ) were recorded . RESULTS VAS scores were similar at 12 , 24 , 36 , and 48 h postsurgery ( P > 0.05 ) , but AA group scores were lower than those of the control group at 3 , 4 , 5 , and 7 days ( P < 0.05 ) . Patients in the AA group consumed lower doses of analgesic than those in the control group after surgery ( P < 0.05 ) . The incidence of analgesia-related adverse effects in the AA group was lower than that in the control group ( P < 0.05 ) . Although HSS scores were similar in the two groups preoperatively and at 3 months postoperatively ( P > 0.05 ) , HSS scores 2 weeks postoperatively were higher in the AA group than in the control group ( P < 0.05 ) , but there was no difference between groups in ROM ( P > 0.05 ) . CONCLUSIONS Applying auricular acupoint acupressure in the perioperative period of TKA is favorable for alleviating postoperative pain , decreasing opioid consumption and its adverse effects , and promoting early rehabilitation . Also , this intervention has the advantage of lower costs , fewer complications , simple application , and high safety Background In Denmark , approximately 12,000 hip and knee arthroplasties were performed in 2006 , and the hospital costs were close to US$ 110,000,000 . In a r and omized clinical trial , we have recently demonstrated the efficacy of accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty compared to current intervention under ideal circumstances . We do not , however , know whether these results could be reached under usual circumstances of healthcare practice . We therefore investigated whether length of stay after implementation of accelerated perioperative care and rehabilitation after hip and knee arthroplasty could be reduced in a normal healthcare setting , and how the achieved results matched those observed during the r and omized clinical trial . Methods An effectiveness study as a before-after trial was undertaken in which all elective primary total hip and total knee arthroplasty patients were divided into a before-implementation group receiving the current perioperative procedure , and an after-implementation group receiving the new accelerated perioperative care and rehabilitation procedures as provided by a new multi-disciplinary organization . We used the Breakthrough Series Collaborative Model for implementation . The primary outcome measure was in hospital length of stay ( LOS ) , and the secondary outcome measure was adverse effects within 3 months postoperatively .  Results We included a total of 247 patients .  Mean LOS was significantly ( P < 0.001 ) reduced by 4.4 ( 95 % CI 3.8–5.0 ) days after implementation of the accelerated intervention , from 8.8 ( SD 3.0 ) days before implementation to 4.3 ( SD 1.8 ) days after implementation . No significant differences in adverse effects were observed . LOS in this effectiveness study was significantly lower than LOS reported in the efficacy study . Conclusion Accelerated perioperative care and rehabilitation intervention after hip and knee arthroplasty was successfully and effectively implemented . Results obtained during usual hospital circumstances matched the results achieved under ideal circumstances in this group of patients Local infiltration anesthesia ( LIA ) with anesthetics , steroids , NSAIDS , and epinephrine has been shown to be effective in reducing total knee arthroplasty ( TKA ) postoperative pain . This systematic review explores the functional outcomes of r and omized control trials that have compared the use of LIA with and without steroids during TKA . Five studies with 412 patients met the inclusion criteria , 228 received local infiltration anesthesia with steroids ( LIAS ) and 184 received local infiltration anesthesia without steroids ( LIAWS ) . The use of LIAS in management of postoperative TKA pain has been shown to decrease the length of hospital stay , time required to achieve straight leg raise , and pro-inflammatory signals in patients . Although there is no overwhelming data to suggest LIAS  improves postoperative TKA pain , current literature does support its effectiveness in producing other favorable surgical outcomes BACKGROUND Total knee arthroplasty ( TKA ) is associated with substantial blood loss in postoperative period . Tranexamic acid ( TXA ) is potent antifibrinolytic agent , routinely administered by intravenous ( IV ) and topical route , which can possibly interrupt cascade of events due to hemostatic irregularities close to source of bleeding . However , scientific evidence of combined administration of TXA in TKA is still meagre . The present study aim ed to compare efficacy of combined IV and topical TXA with IV use alone in terms of blood loss , transfusion rate , and incidence of deep vein thrombosis and thromboembolism . PATIENTS AND METHODS 119 patients undergoing unilateral TKA were r and omized into IV alone and combined group . Patients assigned to IV group were given IV TXA as a preoperative and postoperative dose given 3 and 6 hours after surgery , whereas in combined group , topical TXA solution was applied intraarticularly about 5 minutes before closure of arthrotomy in addition to IV doses . RESULTS Combined use of IV and topical TXA provided better results than IV use alone with mean calculated total blood loss ( 590.69±191.1 vs 385.68±182.5 , P<.001 ) , blood transfusion rate ( 6.6 % vs 1.6 % , P = .364 ) , hemoglobin drop ( 1.82±0.6 vs 1.14±0.5 , P<.001 ) . No case of DVT or TE was noted among the 2 study groups . CONCLUSION Combined use of IV and intraarticular TXA provided significantly better results compared with IV use alone with respect to all variables related to postoperative blood loss in TKA . Moreover , TXA use is safe in terms of incidence of symptomatic DVT and TE Postoperative length of stay ( LOS ) may be affected by more intensive physical therapy following surgery . This study was design ed to assess whether LOS could be affected by weekend physical therapy following surgery in patients who had undergone total hip arthroplasty ( THA ) or total knee arthroplasty ( TKA ) . Weekend coverage for these patients was made possible by increased staffing in the Physical Therapy Department . The study group consisted of 84 patients who had undergone THA or TKA and had physical therapy treatment the weekend following surgery . The Control group consisted of 53 patients who had undergone THA or TKA prior to the implementation of the weekend intervention program .  A retrospective chart audit was used to obtain pertinent information about control group patients . In the total sample mean LOS following weekend therapy ( 10.84 days ) was significantly different ( p < 0.05 ) from mean LOS prior to implementation of the study ( 12.28 days ) . Significant decreases in postoperative LOS were also found within the two subgroups of patients who had undergone THA and TKA . The results indicate that physical therapy treatment the weekend following THA or TKA significantly decreases postoperative LOS when physical therapy re sources are increased to accommo date this increase in coverage OBJECTIVE To investigate the efficacy and safety of tranexamic acid ( TXA ) injection during primary total knee arthroplasty ( TKA ) for reducing postoperative hemorrhage . METHODS 100 cases of patients admitted to our hospital and underwent primary unilateral TKA from January 2012 to December 2014 were enrolled in this study and they were divided r and omly into two groups . For the TXA group , 1 g TXA was dissolved in 50 ml 0.9 % sodium chloride solution and injected after prosthesis implantation but before cavity close . Conventional drainage clamping was carried for 4 h and the drainage tube was removed 48 h postoperative . For the control group , similar measures were taken except for that no TXA was dissolved in 0.9 % sodium chloride solution . Postoperative hemoglobin , blood coagulation index , total blood loss volume , drainage volume , blood transfusion rate and lower extremity deep vein thrombosis ( DVT ) rate in both groups were observed and the efficacy and safety of this surgical treatment were evaluated . RESULTS There were no significant differences in operation time , postoperative platelet and APPT , D-dimer , lower limb venous thrombosis incidence rate 1 week after operation between the two groups . Postoperative drainage volume , hemoglobin , total blood loss and blood transfusion rate in the TXA group were significantly lower than those of the control group . Ecchymosis of lower extremity peripheral incision and its surroundings was significantly milder than that of the control group . CONCLUSION Intraoperative intra-articular injection of TXA in TKA can significantly reduce the initial postoperative hemorrhage and blood transfusion rate at the early stage after operation STUDY OBJECTIVE To determine the perioperative frequency of  deep vein thrombosis ( DVT ) after lower limb joint prosthesis surgery using Doppler ultrasonography ( US ) . DESIGN Prospect i ve cohort study . SETTING Operating room and hospital ward . PATIENTS 144 consecutive ASA physical status 1 and 2 patients who underwent elective total hip arthroplasty ( THA ; n=64 ) or total knee arthroplasty ( TKA ; n= 80 ) . INTERVENTIONS Patients were allocated to two groups , those who developed DVT ( DVT group ) postoperatively and those who did not ( no-DVT group ) . To examine the perioperative risk factors for DVT after THA or TKA , comparative analysis of the two groups was done . MEASUREMENTS Doppler US was performed on all patients from the bilateral femoral to lower limb to detect the existence of DVT postoperatively . MAIN RESULTS DVT was detected in 61 patients ( 42 % ) , including three proximal DVT patients ( 2 % ) . Preoperative elevated plasma D-dimer value [ P = 0.0131 , odds ratio ( OR ) 1.54 , 95 % CI 1.10 - 2.17 ] and history of hyperlipidemia ( P = 0.0453 , OR 6.92 , 95 % CI 1.04 - 46.00 ] were significant risk factors for the onset of DVT . A preoperative plasma D-dimer cutoff value as a diagnostic test was obtained as 0.85 μg/mL. CONCLUSIONS A high preoperative plasma D-dimer value and /or history of hyperlipidemia were risk factors for DVT after THA or TKA OBJECTIVE To evaluate if the timing of aquatic therapy influences clinical outcomes after total knee arthroplasty ( TKA ) or total hip arthroplasty ( THA ) . DESIGN Multicenter r and omized controlled trial with 3- , 6- , 12- , and 24-month follow-up . SETTING Two university hospitals , 1 municipal hospital , and 1 rural hospital . PARTICIPANTS Patients ( N=465 ) undergoing primary THA ( n=280 ) or TKA ( n=185 ) : 156 men , 309 women . INTERVENTION Patients were r and omly assigned to receive aquatic therapy ( pool exercises aim ed at training of proprioception , coordination , and strengthening ) after 6 versus 14 days after THA or TKA . MAIN OUTCOME MEASURES Primary outcome was self-reported physical function as measured by the Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) at 3- , 6- , 12- , and 24-months postoperatively . Results were compared with published thresholds for minimal clinical ly important improvements . Secondary outcomes included the Medical Outcomes Study 36-Item Short-Form Health Survey , Lequesne-Hip/Knee-Score , WOMAC-pain and stiffness scores , and patient satisfaction . RESULTS Baseline characteristics of the 2 groups were similar . Analyzing the total study population did not result in statistically significant differences at all follow-ups . However , when performing sub analysis for THA and TKA , opposite effects of early aquatic therapy were seen between TKA and THA . After TKA all WOMAC subscales were superior in the early aquatic therapy group , with effect sizes of WOMAC physical function ranging from .22 to .39 . After THA , however , all outcomes were superior in the late aquatic therapy group , with WOMAC effect sizes ranging from .01 to .19 . However , the differences between treatment groups of these subanalyses were not statistically significant . CONCLUSIONS Early start of aquatic therapy had contrary effects after TKA when compared with THA and it influenced clinical outcomes after TKA . Although the treatment differences did not achieve statistically significance , the effect size for early aquatic therapy after TKA had the same magnitude as the effect size of nonsteroidal anti-inflammatory drugs in the treatment of osteoarthritis of the knee . However , the results of this study do not support the use of early aquatic therapy after THA . The timing of physiotherapeutic interventions has to be clearly defined when conducting studies to evaluate the effect of physiotherapeutic interventions after TKA and THA Abstract The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased . We hypothesized same-day discharge following either a unicompartmental ( UKA ) or total knee arthroplasty ( TKA ) in an unselected group of patients would not result in a higher perioperative complication rate than st and ard-length hospitalization when following a comprehensive perioperative clinical pathway , including preoperative teaching , regional anesthesia , preemptive oral analgesia , preemptive antiemetics , and a rapid rehabilitation protocol . We prospect ively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospect ively ; 25 had UKA and 86 TKA . Of the 111 patients , 104 ( 94 % , 24 with UKA and 80 with TKA ) met discharge criteria and were discharged directly to home the day of surgery . Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge . There were four ( 3.6 % ) readmissions ( all with TKA ) and one emergency room visit without readmission ( in a patient with a TKA ) within the first week after surgery , while there were four subsequent readmissions ( 3.6 % ) and one additional emergency room visit without readmission within three months of surgery , all among patients undergoing TKA . There were no deaths , cardiac events , or pulmonary complications during this study . Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization . Level of Evidence : Level IV , therapeutic study . See Guidelines for Authors for a complete description of levels of evidence Although avoiding patellar eversion during a total knee arthroplasty ( TKA ) has theoretical benefit in quadriceps recovery , there has been paucity of supportive objective clinical results . We prospect ively design ed the study whether TKA without patellar eversion has better quadriceps recovery in an objective , dynamometer study . Seventy-two knees undergoing TKA with midvastus approach  were r and omized into two groups according to patellar eversion or not . Clinical data and objective quadriceps recovery using a dynamometer were investigated preoperatively and postoperative at 6weeks , 3months , 6months and 1year . There were no statistical differences between two groups throughout the follow-up periods in recovery of quadriceps force or power and clinical data . Choosing to evert patella during TKA using midvastus approach would not adversely affect postoperative quadriceps recovery
Meta- analysis showed that high-dose systemic steroid ( dexamethasone > 0.1 mg/kg ) rather than low dose is effective to reduce postoperative nausea and vomiting and postoperative acute pain ( within 24 h ) .
In addition , systemic steroid is associated within faster functional rehabilitation and greater inflammation control .
On the other h and , systemic steroid is associated with a higher level of postoperative serum glucose on the operation day .
Conclusions Our study suggests that by providing lower incidence of postoperative nausea and vomiting and less postoperative acute pain , high-dose systemic steroid plays a critical role in rapid recovery to TKA and THA .
The preliminary results also show the superior possibility of systemic steroid in functional rehabilitation and inflammation control .
Background Perioperative systemic steroid administration for rapid recovery in total knee and hip arthroplasty ( TKA/THA ) is an important and controversial topic .
We conducted this systematic review and meta- analysis to evaluate the overall benefits and harms of perioperative systemic steroid in patients undergoing TKA and THA .