Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end-stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and retention of urine, which limit their application in daily clinical practice. The aim of this review was to discuss the current postoperative pain management regimens for TKA. Our review of the literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, peripheral nerve blockade, patient-controlled analgesia and local infiltration analgesia, and oral opioid/nonopioid medications. Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/os.12535

Postoperative Pain Management in Total Knee Arthroplasty

The management of pain.

This meta-analysis was designed to compare the longevity of the survivorship of opening versus closing wedge high tibial osteotomy (HTO). All studies reporting survival rates in patients who underwent open or closed wedge HTO with more than 5-year follow-up duration were included in the meta-analysis. Survival time was considered as time to conversion to TKA. Twenty three studies were included in meta-analysis, 20 of which were of level IV evidence. The pooled 5-year survival rates were 95.1% (95% CI: 93.1 to 97.1%) in open wedge HTO and 93.9% (95% CI: 93.1 to 94.6%) in closed wedge HTO. Although there was 1.2% greater survival rate in open wedge HTO than in closed wedge HTO, this difference did not reach statistical significance (P = 0.419). Pooled 10-year survival rates were 91.6% (95% CI: 88.5 to 94.8%) in open wedge HTO and 85.4% (95% CI: 84.0 to 86.7%) in closed wedge HTO, indicating that open wedge HTO had 6.2% greater survival rate 10 years after surgery than did closed wedge HTO (P = 0.002). No difference in 5-year survivorship was found between open- and closed-wedge HTO. However, the survival rate was higher in open-wedge HTOs than in closed wedge HTO at 10 years.

/pdf/survival-of-opening-versus-closing-wedge-high-tibial-1vyzt4r02a.pdf

Survival of opening versus closing wedge high tibial osteotomy: A meta-analysis

Several recent studies have reported accurate and reliable use of patient-specific cutting guides (PSCG) for medial opening-wedge high tibial osteotomy (OW-HTO); however, a majority of these are small cases series or ex-vivo reports. The hypothesis of this study was that performing an OW-HTO with PSCG results in a reliable and accurate correction with good or satisfactory patient-reported functional outcomes at a mean of two years. We also hypothesized that the use of PSCG would not increase the rate of specific or non-specific complications. In this single-centre, observational study, a prospective cohort of a hundred patients (age  0.05) were observed between the desired correction defined pre-operatively and the correction obtained post-operatively (ΔHKA, ΔMPTA, ΔPPTA). An improvement of 27 ± 25 for the KOOS Pain, 28 ± 26 for the KOOS symptoms, 27 ± 28 for the KOOS ADL, 26 ± 33 for the KOOS sport/rec, 28 ± 38 for the KOOS QOL, and 2.6 ± 2.4 for the UCLA was obtained as compared with the pre-operative values (all p < 0.0001). No procedures observed were abandoned, and the PSCG was well positioned in all cases. The overall complication rate was 32% up to two years post-operatively, most of them being classed as minor events (28%). Performing an OW-HTO with PSCG produces an accurate correction with good functional outcomes at a mean of two years. Furthermore, there is no increase in the rate of specific or non-specific complications. A study to assess the reproducibility of this technique, regardless of the surgical level, is needed.

Patient-specific cutting guides for open-wedge high tibial osteotomy: safety and accuracy analysis of a hundred patients continuous cohort.

Purpose The purpose of this retrospective study was to evaluate the survival rates and analyze the factors that affect survival rate after primary treatment with medial open wedge high tibial osteotomy (MOWHTO) for medial unicompartmental knee osteoarthritis. Methods Clinical evaluation using Knee Society Score (KSS) and Western Ontario and McMaster Universities Osteoarthritis Index score and radiographic evaluation, including mechanical axis, were done before and after surgery. The main failure criteria for survival included the conversion to total knee arthroplasty or KSS of Results Three hundred thirty-nine knees were included after a minimum of 5 years' follow-up. Their mean age was 56 years, and mean follow-up duration was 9.6 years. The mean KSS and Western Ontario and McMaster Universities Osteoarthritis Index scores were significantly improved after surgery (87.3 and 18.5 points at 5 years and 81.7 and 23.6 points at 10 years). The mean hip-knee-ankle (HKA) angle was corrected from 7.2° varus to 3.4° valgus 1 year after surgery, which was maintained until 10 years after surgery (2.9° valgus at 5 years and 2.3° valgus at 10 years, P > .05). Using Kaplan-Meier survival estimates, the probability of survival for MOWHTO was 96.8% at 5 years, 87.1% at 10 years, and 85.3% at 13 years. The multivariate regression analysis revealed that age ≥65 years (hazard ratio [HR] = 2.34, P = .046), medial compartment cartilage damage International Cartilage Repair Society grade ≥4 (HR = 2.46, I = .045), lateral compartment cartilage damage International Cartilage Repair Society grade≥2 (HR = 3.38, P = .006), postoperative HKA angle Conclusion MOWHTO seems to be a good treatment option for young and active patients with medial knee osteoarthrosis and varus alignment, with acceptable survival rates and satisfactory outcomes. Age ≥65 years, grade 4 cartilage damage in medial compartment, grade ≥2 cartilage damage in lateral compartment, and undercorrection of HKA angle appear to be significant risk factors associated with failure. Level of Evidence Level IV: retrospective case series.

Survival and Risk Factor Analysis of Medial Open Wedge High Tibial Osteotomy for Unicompartment Knee Osteoarthritis.

Purpose The purpose of this study was to investigate complications and radiologic and clinical outcomes of medial opening wedge high tibial osteotomy (MOWHTO) using a locking plate. Materials and Methods This study reviewed 167 patients who were treated with MOWHTO using a locking plate from May 2012 to June 2014. Patients without complications were classified into group 1 and those with complications into group 2. Medical records, operative notes, and radiographs were retrospectively reviewed to identify complications. Clinically, Oxford Knee score and Knee Injury and Osteoarthritis Outcome score (KOOS) were evaluated. Results Overall, complications were observed in 49 patients (29.3%). Minor complications included lateral cortex fracture (15.6%), neuropathy (3.6%), correction loss (2.4%), hematoma (2.4%), delayed union (2.4%), delayed wound healing (2.4%), postoperative stiffness (1.2%), hardware irritation (1.2%), tendinitis (1.2%), and hardware failure without associated symptoms (0.6%). Major complications included hardware failure with associated symptoms (0.6%), deep infection (0.6%), and nonunion (0.6%). At the first-year follow-up, there were no significant differences in radiologic measurements between groups 1 and 2. There were no significant differences in knee scores except for the KOOS pain score. Conclusions Our data showed that almost all complications of the treatment were minor and the patients recovered without any problems. Most complications did not have a significant impact on radiologic and clinical outcomes.

Complications and Short-Term Outcomes of Medial Opening Wedge High Tibial Osteotomy Using a Locking Plate for Medial Osteoarthritis of the Knee

Background
This study aimed to compare the effects of femoral nerve block and adductor canal block on postoperative pain, quadriceps strength, and walking ability after primary total knee arthroplasty.

/pdf/comparison-of-the-effect-of-continuous-femoral-nerve-block-1bq6vtnjbk.pdf

Comparison of the Effect of Continuous Femoral Nerve Block and Adductor Canal Block after Primary Total Knee Arthroplasty.

Purpose To evaluate clinical and radiological outcome of the full cementation technique in revision total knee arthroplasty (TKA) using a constrained condylar knee (CCK) prosthesis. Materials and Methods Between January 2008 and March 2012, 18 cases (16 patients) of fully cemented revision TKA were performed using a CCK prosthesis. Fifteen cases of aseptic loosening (13 patients) and 3 cases of infection were included. There were 2 males and 14 females with a mean age of 76.7 years at the time of surgery, and the average follow-up was 81 months. Clinically, the pain score, function score and Hospital for Special Surgery (HSS) score were evaluated. Radiologically, loosening, radiolucent lines and migration of implant were evaluated. Results Preoperatively, the pain score, function score and HSS score were 50.3, 24.4 and 61.8 points, respectively. At the latest follow-up, the scores were improved to 84.8, 63.6 and 85.6 points, respectively (p<0.05). Loosening or migration of implant was not observed in any cases. Radiolucent lines were observed in 5 cases underneath the tibial component without progression during the follow-up. Conclusions The full cementation technique in revision TKA using a CCK showed excellent clinical results. Although radiolucent lines were observed in 27.8% underneath the tibial component, there was no progression to loosening or instability.

Full Cementation in Revision Total Knee Arthroplasty Using a Constrained Condylar Knee Prosthesis with an Average 7-Year Follow-up

The radial variation of rays within the stems of Dahurian larch and Japanese larch growing in Korea was studied to obtain valuable information to identify the two species and determine wood quality. Uniseriate ray height, fusiform ray height, ray number, ray spacing, and epithelial cell number were investigated by optical microscopy. The heights of uniseriate and fusiform rays and epithelial cell numbers in Dahurian larch were lower than those in Japanese larch. Dahurian larch wood had greater ray number and ray spacing than Japanese larch wood. In both species, the heights of uniseriate and fusiform rays and epithelial cell number increased with increasing growth ring number but then stabilized from a certain growth ring number. However, ray number and ray spacing decreased with age but were stable toward the bark. There were significant differences in all ray properties between the two species. Furthermore, in both species, the number and spacing of rays showed a significant negative correlation with uniseriate ray height. The relationships between uniseriate and fusiform ray height, and between ray spacing and ray number were significantly positive. In conclusion, the results from this study provide basic information that can be used to identify these species, and the quality indices from ray properties will improve the effective utilization of the two woody species.

Ray properties in the stems of Dahurian larch (Larix gmelinii) and Japanese larch (Larix kaempferi)

Species composition and community structure of fish by shrimp beam trawl between Sacheon Bay and coastal waters off Namhae, Korea

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