Akiho Hoshino

Postoperative epidural analgesia compared with intraoperative periarticular injection for pain control following total knee arthroplasty under spinal anesthesia: a randomized controlled trial.

BACKGROUND Although epidural analgesia has been used for postoperative pain control after total knee arthroplasty, its usefulness is being reevaluated because of possible adverse effects. Recent studies have proven the efficacy of periarticular analgesic injection and its low prevalence of adverse effects. The present study compares the clinical efficacies of epidural analgesia and periarticular injection after total knee arthroplasty. METHODS This is a prospective, single-center, randomized controlled trial involving patients scheduled for unilateral total knee arthroplasty. One hundred and eleven patients were randomly assigned to periarticular injection or epidural analgesia groups. All patients were managed with spinal anesthesia. The surgical technique and postoperative medication protocol were identical in both groups. The primary outcome was postoperative pain at rest, quantified as the area under the curve of the scores on a visual analog pain scale to seventy-two hours postoperatively. The Student t test and chi-square test were used to compare the data between groups. RESULTS In the intention-to-treat analysis, the periarticular injection group had a significantly lower area under the curve for pain score at rest (788.0 versus 1065.9; p = 0.0059). In the periarticular injection group, the mean knee flexion angle was small but significantly better at postoperative day 1 (64.2° versus 54.6°; p = 0.0072) and postoperative day 2 (70.3° versus 64.6°; p = 0.021) than in the epidural analgesia group. The incidence of nausea at postoperative day 1 was significantly lower in the periarticular injection group (4.0% versus 44.3%; p < 0.0001). Transient peroneal nerve palsy was frequently seen in the periarticular injection group (12.0% versus 1.6%; p = 0.026). CONCLUSIONS Compared with epidural analgesia, periarticular injection offers better postoperative pain relief, earlier recovery of knee flexion angle, and lower incidence of nausea. Care should be taken to avoid transient peroneal nerve palsy when using periarticular injection. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intermediate-Term Results of Meniscal Repair in Anterior Cruciate Ligament-Reconstructed Knees

We investigated the incidence of and risk factors for recurrent tears of repaired menisci in anterior cruciate ligament-reconstructed knees. We observed 63 patients whose menisci had been evaluated at second-look arthroscopy as healed (N = 50) or incompletely healed (N = 13) for an average of 4 years (range, 2 to 9.5). Of the 13 patients with incompletely healed menisci, 6 (46%) required additional meniscal surgery and 2 (15%) had recurrence of meniscal symptoms such as catching or locking. Among the 50 patients with healed menisci, 5 (10%) required additional meniscal surgery and 9 (18%) had recurrence of meniscal symptoms after second-look arthroscopy. The timing of the recurrence of these symptoms was from 12 to 28 months after surgical repair. Of the 11 patients who had undergone additional surgery, 6 had sustained second injuries during sports activities and the other 5 had no identifiable cause of injury. When comparing age, tear sites, rim width, side-to-side differences with KT-1000 arthrometer testing, and the pivot shift test, there were no differences between the group requiring additional surgery, the symptomatic group, and the asymptomatic group. However, the postoperative Tegner activity score of the group requiring additional surgery was statistically significantly higher than the others.

A simple radiographic measurement method for polyethylene wear in total knee arthroplasty

This study describes a new method for evaluating polyethylene wear in total knee arthroplasty. Since the amount of wear is dependent on a number of variables such as the weight and activity of the patient, it should be estimated based on in vivo measurements. We used a computer vision technique called three-dimensional/two-dimensional (3-D/2-D) matching to perform in vivo assessment using a single-plane radiograph. Using the 3-D/2-D matching algorithm we estimated the 3-D position and orientation of each knee implant and then measured the femorotibial distance, which is defined as the shortest perpendicular distance from the tibial tray to the femoral component. The accuracy of the proposed 3-D/2-D matching method was determined by in vitro investigations. The worst errors in in-plane/out-of-plane translations and rotations were 0.20/1.95 mm and 0.17/0.29 degrees, respectively. The root-mean-square error in femorotibial distance measurements using real polyethylene inserts was 0.04 mm. Results of in vivo femorotibial distance measurements are also described.

The impact of including corticosteroid in a periarticular injection for pain control after total knee arthroplasty: a double-blind randomised controlled trial

There is conflicting evidence about the benefit of using corticosteroid in periarticular injections for pain relief after total knee arthroplasty (TKA). We carried out a double-blinded, randomised controlled trial to assess the efficacy of using corticosteroid in a periarticular injection to control pain after TKA. A total of 77 patients, 67 women and ten men, with a mean age of 74 years (47 to 88) who were about to undergo unilateral TKA were randomly assigned to have a periarticular injection with or without corticosteroid. The primary outcome was post-operative pain at rest during the first 24 hours after surgery, measured every two hours using a visual analogue pain scale score. The cumulative pain score was quantified using the area under the curve. The corticosteroid group had a significantly lower cumulative pain score than the no-corticosteroid group during the first 24 hours after surgery (mean area under the curve 139, 0 to 560, and 264, 0 to 1460; p = 0.024). The rate of complications, including surgical site infection, was not significantly different between the two groups up to one year post-operatively. The addition of corticosteroid to the periarticular injection significantly decreased early post-operative pain. Further studies are needed to confirm the safety of corticosteroid in periarticular injection. Take home message: The use of corticosteroid in periarticular injection offered better pain relief during the initial 24 hours after TKA. Cite this article: Bone Joint J 2016;98-B:194–200.

Pain Control After Simultaneous Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial Comparing Periarticular Injection and Epidural Analgesia

BACKGROUND Periarticular injection is becoming more commonly utilized for pain relief following total knee arthroplasty. However, we are aware of no randomized controlled trial that has investigated the efficacy of periarticular injection for pain relief after simultaneous bilateral total knee arthroplasty. METHODS We performed a randomized controlled trial of patients scheduled for simultaneous bilateral total knee arthroplasty. Seventy-one patients with 142 involved knees were randomly assigned to receive periarticular injection or epidural analgesia. Other perioperative interventions, including spinal anesthesia, surgical techniques, and postoperative medication protocols, were identical for all patients. The primary outcome was postoperative pain at rest, measured with the use of a 100-mm visual analog scale (VAS) during the initial twenty-four-hour postoperative period. The cumulative VAS score was calculated with use of the area under the curve and compared between the groups. RESULTS Postoperative pain at rest, quantified as the area under the curve of serial assessments during the initial twenty-four-hour postoperative period, was significantly less in the periarticular injection group than in the epidural analgesia group (174.9 ± 181.5 mm × day compared with 360.4 ± 360.6 mm × day; p = 0.0073). The prevalences of nausea on the night of surgery and postoperative day 1 and of pruritus were significantly lower in the periarticular injection group than in the epidural analgesia group (14% and 45%, p = 0.0031; 14% and 55%, p = 0.0003; and 0% and 15%, p = 0.014, respectively). CONCLUSIONS Periarticular injection was associated with better pain relief during the first twenty-four hours following simultaneous bilateral total knee arthroplasty and decreased opioid-related side effects compared with epidural analgesia. Periarticular injection may be preferable to epidural analgesia for pain relief after simultaneous bilateral total knee arthroplasty.

The Long-term Effects of Tibial Drill Hole Position on the Outcome of Anterior Cruciate Ligament Reconstruction

Fifty-three cases of anterior cruciate ligament reconstruction were classified into two groups depending on the tibial drill hole position: in the anterior group, the center of tibial drill hole was positioned anteriorly to the dome of the intercondylar notch (Blumensaats line), and in the posterior group, it was positioned posteriorly to the Blumensaats line. Knee extension loss in the anterior group was significantly greater at 1 and 2 years postoperatively than that of the posterior group. However, there were no differences between the anterior and posterior groups 3 to 5 years postoperatively. No significant differences in anterior laxity were seen from 1 to 4 years postoperatively. After more than 5 years, anteroposterior translation of the anterior group was significantly greater than that of the posterior group. In the anterior group, extension was restricted in the early postoperative period. At latest follow-up more than 5 years postoperatively, anterior laxity in the posterior group was significantly less than that in the anterior group.

Intramedullary screw fixation with bone autografting to treat proximal fifth metatarsal metaphyseal-diaphyseal fracture in athletes: a case series

BackgroundDelayed unions or refractures are not rare following surgical treatment for proximal fifth metatarsal metaphyseal-diaphyseal fractures. Intramedullary screw fixation with bone autografting has the potential to resolve the issue. The purpose of this study was to evaluate the result of the procedure.MethodsThe authors retrospectively reviewed 15 athletes who underwent surgical treatment for proximal fifth metatarsal metaphyseal-diaphyseal fracture. Surgery involved intramedullary cannulated cancellous screw fixation after curettage of the fracture site, followed by bone autografting. Postoperatively, patients remain non weight-bearing in a splint or cast for two weeks and without immobilization for an additional two weeks. Full weight-bearing was allowed six weeks postoperatively. Running was permitted after radiographic bone union, and return-to-play was approved after gradually increasing the intensity.ResultsAll patients returned to their previous level of athletic competition. Mean times to bone union, initiation of running, and return-to-play were 8.4, 8.8, and 12.1 weeks, respectively. Although no delayed unions or refractures was observed, distal diaphyseal stress fractures at the distal tip of the screw occurred in two patients and a thermal necrosis of skin occurred in one patient.ConclusionsThere were no delayed unions or refractures among patients after carrying out a procedure in which bone grafts were routinely performed, combined with adequate periods of immobilization and non weight-bearing. These findings suggest that this procedure may be useful option for athletes to assuring return to competition level.

Accurate 3D pose estimation method for polyethylene wear assessment in total knee replacement

This study describes a new method for evaluating polyethylene wear in total knee prosthesis. Since the amount of wear is dependent on a number of variables such as weight and activity of the patient, the amount should be estimated based on in-vivo measurement. A computer vision technique called 3D/2D matching is employed to perform in-vivo assessment using single-plane radiograph. By the 3D/2D matching algorithm the three-dimensional position and orientation (pose) of knee implants is estimated to measure the femorotibial distance which is defined as the shortest perpendicular distance from the tibial tray to the femoral component. The accuracy of the proposed 3D/2D matching method is demonstrated on some in-vitro investigations. Pose estimation errors are examined and the maximum error in in-plane/out-of-plane translations and rotations 0.28/4.17 mm and 0.33/0.26 degrees, respectively. That in femorotibial distance measurements is 0.14 mm.

Kinematics measurement of mobile bearing total knee arthroplasty

The presented study describes a new method to measure kinematics of the polyethylene insert in mobile bearing total knee arthroplasty. The method estimates the three-dimensional position/orientation of the insert from a single-plane X-ray photograph using projected points of some metal balls which are embedded in the insert. The kinematics can be measured with an accuracy of 0.19 mm or better.