Kathleen L. Dodds

Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty.

The purpose of this study was to determine if an intraoperative intraarticular and soft-tissue injection of local anaesthetic, epinephrine, and morphine has a beneficial effect for total knee arthroplasty. A control group of 138 patients (181 knees) received no intraoperative injection. The study group of 171 patients (197 knees) received intraoperative injection of 0.25% bupivacaine with epinephrine and morphine with 2/3 injected into the soft tissues and 1/3 injected into the joint. Patients having bilateral simultaneous procedures received a divided dose. The pain treatment protocol otherwise was identical. Pain, sedation, rescue narcotic usage, narcotic reversal and blood loss were examined. Pain levels during the immediate postoperative period, blood loss, and bleeding indices were reduced with injection. Considerably more control patients required rescue doses of narcotics. Preemptive analgesia with soft tissue and intra-articular injection of long-acting local anesthetic with epinephrine and morphine provides better pain control in the immediate postoperative period, decreases blood loss, and decreases the need for rescue narcotics and reversal agents. This simple, inexpensive method provides an effective adjunct to a multimodal approach in improving the postoperative course of primary total knee arthroplasty.

Simultaneous bilateral total knee arthroplasties: who decides?

The purpose of the current retrospective review was to compare the results of 1498 patients having 1090 simultaneous bilateral total knee arthroplasties and 958 unilateral total knee arthroplasties in a 3-year period, focusing on perioperative complications, length of hospital stay, and discharge disposition. Gender, age, diagnosis, and weight were similar between the groups. Patients undergoing simultaneous bilateral total knee arthroplasties had statistically significant higher amounts of intraoperative blood loss, with more patients requiring blood transfusion, and a higher average number of units of blood transfused compared with patients undergoing unilateral total knee arthroplasty. Overall, a significantly higher incidence of gastrointestinal complications was reported in patients who had simultaneous bilateral knee arthroplasties compared with patients who had unilateral knee arthroplasty. Comparing age subgroups within the unilateral group revealed significantly higher incidences of pulmonary, neurologic, cardiac, and genitourinary complications among patients 80 years or older versus patients younger than 80 years. Patients having simultaneous bilateral arthroplasties who were 80 years or older had significantly higher incidences of pulmonary, neurologic, and cardiac complications than patients younger than 80 years in that same group. These results suggest that age, not procedure, has a more significant role in the perioperative morbidity of total knee arthroplasty. Based on the results from the current study and previous literature documenting patient preference, patient satisfaction, efficacy, and outcomes comparable with those of patients having unilateral total knee arthroplasty, the authors continue to offer patients the option of simultaneous bilateral total knee arthroplasties.

An Algorithmic Approach to Total Knee Arthroplasty in the Valgus Knee

The valgus arthritic knee presents as a complex deformity characterized by bone loss involving the lateral femoral condyle, contractures of the lateral soft-tissue structures, and concomitant instability. Patients with end-stage degenerative joint disease and valgus knee deformity have pain, limitation of activities of daily living, increasing angular deformity, and increasing instability. Total knee arthroplasty with valgus release is indicated when both mechanical and pharmacological nonoperative treatment modalities for end-stage degenerative joint disease have failed to relieve pain. The major contraindication to total knee arthroplasty is infection, and relative contraindications include young age, high activity level, and obesity. The following steps should be followed as part of the standard physical examination for end-stage degenerative joint disease: (1) assess the patients gait; (2) establish the presence of deformity (valgus-varus, flexion contracture, or extension contracture); (3) measure the range of motion; (4) evaluate the status of the extensor mechanism and the patellofemoral articulation; (5) assess stability (integrity of the medial collateral ligament); and (6) perform a neurovascular examination. Standard anteroposterior, lateral, Merchant, and alignment radiographs should be included in the diagnostic protocol for candidates for total knee arthroplasty. Fluoroscopic examination may be used to determine the amount of medial instability. A baseline electromyogram should be made for patients presenting with symptoms such as hypoesthesia, dysesthesia, and paresthesia that may be attributed to lumbosacral disease. From a surgical perspective, valgus deformities can be classified into three major variants (I, II, and III) on the basis of the degree of deformity, the status of the medial collateral ligament, and the amount of release that must be performed (Figs. 1-A, 1-B, and 1-C). Variant I, which accounts for 80% of all valgus deformities, occurs secondary to bone loss in the lateral compartment. This variant is characterized by mild deficiencies of the lateral femoral condyle …

Total Femoral Arthroplasty for Salvage of End-stage Prosthetic Disease

The complications and outcomes in patients who had total femoral arthroplasty for salvage of a severely compromised femur were studied. The clinical scenarios included numerous revision total hip or knee arthroplasties, failed periprosthetic fractures, or recurrent infection treated with multiple radical debridement surgeries. Fifty-nine patients (average age, 73.7 years) were identified. At an average 4.8 years followup, adequate pain relief was achieved and Harris hip pain scores averaged 33.8 of 44 points, and knee pain scores averaged 42.8 of 50 points. Good function was achieved with 98% of patients able to ambulate and 43% using no assistive device or a cane only. There were 18 complications or subsequent surgeries. Infection and dislocation occurred in eight patients and seven patients, respectively. Total femoral arthroplasty for salvage of a severely compromised femur provides acceptable results even in the most difficult of cases.

Tapered Cementless Femoral Stem: Difficult to Place in Varus but Performs Well in Those Rare Cases

This retrospective review was conducted to determine the incidence and minimum 5-year follow-up of varus placement of a tapered, proximally plasma-sprayed, titanium femoral component. Twenty-six (2.4%) of 1080 components were placed in > or = 5 degrees of varus in primary cementless total hip arthroplasty at one institution. Harris hip scores improved an average of 50 points. One stem was revised for malposition at 2.5 years, yet was well-fixed by radiographic criteria. Survival with aseptic loosening as an end-point is 100% with an overall femoral component survival of 96% at an average 10-year follow-up. A tapered, titanium component is reliably placed into appropriate position and is forgiving as to varus implant position.