Intra-operative, peri-articular injection of local anaesthesia is an increasingly popular way of controlling pain following total knee replacement. At the same time, the problems associated with allogenic blood transfusion have led to interest in alternative methods for managing blood loss after total knee replacement, including the use of auto-transfusion of fluid from the patient’s surgical drain. It is safe to combine peri-articular infiltration with auto-transfusion from the drain. We performed a randomised clinical trial to compare the concentration of local anaesthetic in the blood and in the fluid collected in the knee drain in patients having either a peri-articular injection or a femoral nerve block. Clinically relevant concentrations of local anaesthetic were found in the fluid from the drains of patients having peri-articular injections (4.92 μg/ml (. sd. 3.151)). However, none of the patients having femoral nerve blockade had detectable levels. None of the patients in either group had clinically relevant concentrations of local anaesthetic in their blood after re-transfusion. The evidence from this study suggests that it is safe to use peri-articular injection in combination with auto-transfusion of blood from peri-articular drains during knee replacement surgery

STUDY PURPOSES. To evaluate the role of “top up” intra-articular local anaesthetic injection in patients who have had UKR. METHOD AND RESULTS. 43 patients scheduled to have a cemented Oxford UKR were prospectively recruited and randomised. All patients had the same initial anaesthetic regime of general anaesthesia, femoral nerve block and intra-operative intra-articular infiltration. All patients had a multi-holed epidural catheter placed intra-articularly prior to wound closure. Patients had the same operative technique, post operative rehabilitation and rescue analgesia. An independent, blinded observer recorded post-operative pain scores using a visual analogue score every 6 hours and any rescue analgesia. On the morning after surgery, 22 patients, (Group I), received 20 mls of 0.5% bupivicaine through the catheter whilst 21, (Group II), patients had 20 mls of normal saline by the same observer, after which the catheter was removed. No statistical difference was found in pain scores on the day of operation between the groups. However, patients in Group I had a significantly better pain score initially post top up and at 6 hours (2.4 (0-8) vs 5.7 (2-9), p<0.001). This cohort of patients required less rescue analgesia (p<0.001). In addition, Group I had statistically significant higher patient satisfaction outcome scores after the infiltration, (p<0.001). CONCLUSION. Our study has shown that injection of local anaesthesia via an intra-articular catheter does reduce pain scores when compared to placebo. This implies that this technique may have a role in providing optimal pain relief after UKR

Purpose. To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure. Methods. We prospectively analysed all patients who required MUA post TKA performed by 2 surgeons using the same prosthesis from 2003 to 2008 and compared them to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. In addition risk factors were identified including warfarin and statin use, diabetes and body mass index. Results. Seventy-two patients required an MUA out of 1313 TKAs (5.5%) and were compared to a control group of 50 patients. The mean arc of motion preoperatively was 89.0° (MUA group) vs 92.2° (control) (p=0.47), at discharge 71.0° vs 76.8° (p<0.05) and 6 weeks follow-up 64.0° vs 97.3° (p<0.0001). Post manipulation the mean arc of motion was 108° on table, 83.1° at 3 months follow-up and 81.9° at 12 months. Patients whose manipulation was within 3 months of TKA (23 patients) improved their mean arc of motion from 53.6° to 78.0° (p<0.0025), those 3-12 months (42 patients) from 67° to 83.0° (p<0.0001) and those >12 months (7 patients) 81° to 89° (p=0.32). Mean increase of extension was 3.7° on table and 3.6° at 12 months. Mean flexion increase was 40.5° on table and 15.7° at 12 months. The relative risk factor for requiring an MUA was 6.97 warfarin (p<0.05), 1.58 statins, 2.85 diabetes and 1.17 obesity. Conclusions. MUA for patients with stiffness after primary TKA improves their range of motion if done within 12 months, however only 40% flexion improvement is maintained. Patients who will require an MUA have a reduced motion at discharge. Patients on warfarin therapy are more likely to get stiffness

Abstract

The purpose of this study was to compare clinical outcomes of total knee arthroplasty (TKA) after manipulation under anaesthesia (MUA) for post-operative stiffness with a matched cohort of TKA patients who did not requre MUA.

In total 72 patients (mean age 59.8 years, 42 to 83) who underwent MUA following TKA were identified from our prospective database and compared with a matched cohort of patients who had undergone TKA without subsequent MUA. Patients were evaluated for range of movement (ROM) and clinical outcome scores (Western Ontario and McMaster Universities Arthritis Index, Short-Form Health Survey, and Knee Society Clinical Rating System) at a mean follow-up of 36.4 months (12 to 120). MUA took place at a mean of nine weeks (5 to 18) after TKA. In patients who required MUA, mean flexion deformity improved from 10° (0° to 25°) to 4.4° (0° to 15°) (p < 0.001), and mean range of flexion improved from 79.8° (65° to 95°) to 116° (80° to 130°) (p < 0.001). There were no statistically significant differences in ROM or functional outcome scores at three months, one year, or two years between those who required MUA and those who did not. There were no complications associated with manipulation.

At most recent follow-up, patients requiring MUA achieved equivalent ROM and clinical outcome scores when compared with a matched control group. While other studies have focused on ROM after manipulation, the current study adds to current literature by supplementing this with functional outcome scores.

Cite this article: Bone Joint J 2015;97-B:1640–4.

This in vivo controlled laboratory study was performed to evaluate various intra-articular clinical injection regimes that might be less toxic than some in vitro studies suggest. We hypothesised that low-concentration, preservative-free, pH-balanced agents would be less toxic than high-concentration non-pH-balanced agents with preservatives, and that injections of individual agents are less toxic than combined injections. The left knees of 12- to 13-week-old Sprague–Dawley rats were injected once with eight different single agents, including low and high concentrations of ropivacaine and triamcinolone, alone and in combination, as well as negative and positive controls. The rats were killed at one week or five months, and live–dead staining was performed to quantify the death of chondrocytes. All injections except pH-balanced 0.2% ropivacaine combined with preservative-free 1 mg/ml triamcinolone acetonide resulted in statistically significant decreases in chondrocyte viability, compared with control knees, after one week and five months (p < 0.001). After one week there was no significant difference in viability between 0.2% and 0.5% ropivacaine; however, 4 mg/ml triamcinolone resulted in a lower viability than 1 mg/ml triamcinolone.

Although many agents commonly injected into joints are chondrotoxic, in this in vivo study diluting preservative-free 10 mg/ml triamcinolone 1:9 in 0.2% pH-balanced ropivacaine resulted in low toxicity.

Cite this article: Bone Joint J 2015; 97-B:933–8.

Aims

Enhanced perioperative protocols have significantly improved patient recovery following primary total knee arthroplasty (TKA). Little has been investigated the effectiveness of these protocols for revision TKA (RTKA). We report on a matched group of aseptic revision and primary TKA patients treated with an identical pain and rehabilitation programmes.

Aims. The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources. Methods. Day-case TKAs, defined as patients discharged on the same calendar day as surgery, were retrospectively reviewed with a minimum follow-up of six months. Analysis of hospital and primary care records was performed to determine readmission and reattendance rates. Telephone interviews were conducted to determine patient satisfaction. Results. Since 2016, 301/7350 TKAs (4.1%) in 290 patients at our institution were discharged on the day of surgery. Mean follow-up was 31.4 months (6.2 to 70.0). In all, 28 patients (9.3%) attended the emergency department or other acute care settings within 90 days of surgery, most often with wound concerns or leg swelling; six patients (2.0%) were readmitted. No patients underwent a subsequent revision procedure, and there were no periprosthetic infections. Two patients (0.7%) underwent secondary patella resurfacing, and one patient underwent arthroscopic arthrolysis after previous manipulation under anaesthetic (MUA). Three patients (1.0%) underwent MUA alone. Primary care consultation records, available for 206 patients, showed 16 patients (7.8%) contacted their general practitioner within two weeks postoperatively; two (1.0%) were referred to secondary care. Overall, 115/121 patients (95%) telephoned stated they would have day-case TKA again. Conclusion. Day-case TKA can be safely delivered in the NHS with no additional resources. We found low incidence of contact with primary and secondary care in the postoperative period, and high patient satisfaction. Cite this article: Bone Jt Open 2023;4(8):621–627

Aims. Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m. 2. (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups. Results. Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication. Conclusion. IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126–130

Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Abstract. Introduction. The rate of day-case total knee replacement (TKR) in the UK is currently ~0.5%. Reducing length of stay improves efficiency, increases operative throughput and tackles the rising demand for joint replacement surgery and the COVID-19 related backlog. We report safe delivery of day-case TKR in an NHS Trust via inpatient wards, with no additional resources. Methodology. Day-case TKRs, defined as patients discharged on the same calendar day as surgery, were retrospectively reviewed with a minimum follow-up of six-months. Analysis of hospital and primary care records was performed to determine readmission and reattendance rates. Telephone interviews were conducted to determine patient satisfaction. Results. Between 2016 and 2021, 301/7350 (4.1%) TKRs were discharged on the day of surgery. Mean follow-up was 31.4 (6.2–70.0) months. 28 (9.3%) patients attended Accident and Emergency or other acute care settings within 90-days of surgery; six (2.0%) patients were readmitted. No patients underwent a subsequent revision procedure. There were no prosthetic infections. Two patients underwent secondary patella resurfacing, and one patient underwent arthroscopic arthrolysis after previous manipulation under anaesthetic (MUA). Three patients underwent MUA alone. Primary care consultation records, available for 206 patients, showed 16 (7.8%) patients contacted their General Practitioner within two-weeks post-operatively; two (1.0%) were referred to secondary care. 115/121 (95%) patients telephoned stated they would have day-case TKR again. Conclusion. Day-case TKR can be safely delivered in the NHS with no additional resources. We found low incidence of contact with primary and secondary care in the post-operative period, and high patient satisfaction

Aims. Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone. Methods. This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain. Results. The study group (mean visual analogue scale (VAS) pain score of 5.5 (SD 0.889)) experienced significant reduction in pain 12 hours after surgery compared to the control group (mean VAS 6.62 (SD 1.356); mean difference = 1.12, 95% confidence interval (CI) -1.46 to 0.67; p < 0.001), and pain scores on postoperative day (POD) 1 and POD-2 were lower in the study group compared to the control group (mean difference in VAS pain = 1.04 (-1.39 to -0.68, 95% CI, p < 0.001). Fewer patients in the study group (0 vs 3 in the control group) required additional analgesia for breakthrough pain, but this was not statistically significant. The study group had significantly increased active knee flexion (mean flexion 86.4° (SD 7.22°)), compared to the control group (mean 73.86° (SD 7.88°), mean difference = 12.54, 95% CI 9.97 to 15.1; p < 0.014). Conclusion. Combined ACB+ ropivacaine infusion via IAC is a safe, reproducible analgesic modality after primary TKA, with superior analgesia compared to ACB alone. Further large volume trials are warranted to generate evidence on clinical significance on analgesia after TKA. Cite this article: Bone Jt Open 2021;2(12):1082–1088

Abstract. Introduction. With respect to survivorship following total knee arthroplasty (TKA), joint registries consistently demonstrate higher revision rates for both sexes in those less than 55 years. The current study analyses the survivorship of 500 cementless TKAs performed in this age group in a high-volume primary joint unit where cementless TKA has traditionally been used for the majority of patients. Methods. This was a retrospective review of 500 consecutive TKAs performed in patients under the age of 55 between March 1994 and April 2017. The primary outcome measure for the study was all-cause revision. Secondary outcome measures included clinical, functional and radiological outcomes. Results. The all-cause revision rate was 1.6% (n=8) at a median of 55.7 months. Four were revised for infection, 2 for stiffness, 1 for aseptic loosening of the tibial component and 1 patella was resurfaced for anterior knee pain. The aseptic revision rate was 0.8% (n=4). Twenty-seven (5.4%) patients underwent a manipulation under anaesthetic (MUA). Including those who underwent MUA, 6.8% (n=34) underwent other non-revision procedures. Conclusion. Survivorship in our unit in this young patient cohort was excellent with an aseptic revision rate of 0.8% at 59.7 months using a fully cementless construct. The MUA rate was higher than expected

Abstract. INTRODUCTION. Geniculate nerve blocks (GNB) and ablation (GNA) are increasing in popularity as strategies for the management of knee pain in patients unsuitable for surgical intervention. Typically these simple blocks have been performed by specialists in pain medicine. We present the results of a GNB clinic run by a surgical care practitioner (SCP). METHODOLOGY. An SCP clinic was created where ultrasound-guided GNBs comprising local anaesthetic and steroid were administered. Patients considered unsuitable for surgery were referred with knee pain by orthopaedic knee surgeons and specialist physiotherapists. A VAS pain score and an Oxford Knee Score (OKS) were completed prior to and immediately following blockade. Serial VAS diaries were completed. Further OKS were requested at 6 weeks and 6 months. Patients could request GNA at any point during follow-up and their follow-up ceased at this stage. RESULTS. 50 patients were identified between December 2020 and 2021. Patients are followed up until 6 months post-block or until referral for GNA. Pre-blockade mean OKS was 13.4, mean VAS 8.6, post procedure mean VAS 2.7. Six-week mean OKS was 20.9 in those not referred for ablation, mean improvement of 7.3. Of the cohort of 50, 25 have progressed to ablation. CONCLUSION. GNB is a simple procedure which can provide both lasting symptomatic relief and prognostic information in the treatment of patients with knee pain not amenable to surgical intervention, a growing subset of patients. This SCP-led clinic increases capacity for the provision of GNBs, helping to identify patients suitable for GNA

Abstract. Introduction. To compare the efficacy of adductor canal blocks (ACB) and periarticular anesthetic injections (PAI) with bupivacaine in total knee arthroplasty. Methods. 90 patients undergoing primary total knee arthroplasty under spinal anesthesia were randomized to 1 of 3 groups: ACB alone (15 mL of 0.5% bupivacaine), PAI alone (50 mL of 0.25% bupivacaine with epinephrine) and ACB + PAI. Primary outcome in this study was the visual analog scale (VAS) pain score in the immediate postoperative period. Secondary outcomes included postoperative opioid use, activity level during physiotheraphy, length of hospital stay and ROM. Results. Mean VAS pain score was significantly higher with ACB alone, compared with the score after use of ACB+PAI, on POD1 and POD3. Total opioid consumption through POD3 was significantly higher when ACB alone had been used compared with PAI alone and ACB+PAI. Opioid consumption in the ACB-alone group was significantly higher than that in the ACB + PAI group on POD2 and POD3 and significantly higher than that in the PAI alone group on POD2. There was no significant difference in opioid consumption between the patients treated with PAI alone and those who received ACB + PAI. The activity level during physiotherapy on POD0 was significantly lower after use of ACB alone than after use of PAI alone or ACB + PAI. Conclusion. Higher pain scores after total knee arthroplasty done with an ACB and without PAI, suggesting that ACB alone is inferior for perioperative pain control. There were no significant differences between ACB alone, PAI alone and ACB + PAI inparameters measured

Abstract. 20% of patients are severely dis-satisfied following total knee arthroplasty (TKA). Arthrofibrosis is a devastating complication preventing normal knee range of motion (ROM), severely impacting patient's daily living activities. A previous RCT demonstrated superiority of a high intensity stretching programme using a novel device the STAK tool compared with standard physiotherapy in TKA patients with arthrofibrosis. This study analyses the results when the previous “standard physiotherapy” group were subsequently treated with the STAK tool. Methods. 15 patients post TKA with severe arthrofibrosis and mean ROM 71° were recruited, (three cases had previously failed manipulation under anaesthetic (MUA). Patients received 8 weeks standard physiotherapy, then treatment with the STAK at home for 8 weeks. ROM, extension, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Scores (OKS) were collected at various time-points. Results. Following standard physiotherapy there were small improvements in ROM (8°) (p<0.01), but no significant improvements in extension, OKS or WOMAC (p=0.39). Following the STAK treatment all outcomes significantly improved (p<0.01). STAK group; mean ROM (21° versus 8°, p < 0.001), extension 9° versus 2° (p < 0.01), WOMAC (18 points versus 3, p < 0.01), and OKS (8 points versus 4, p<0.01). No patients suffered any complications relating to the STAK. Conclusions. The STAK is effective in increasing ROM, extension and function, whilst reducing pain and stiffness. The device can be considered a cost-effective and valuable treatment following TKA. This is likely to increase the overall satisfaction rate and has potential to reduce the need for MUA

Introduction. Manipulation under anesthesia (MUA) remains the gold standard to address restricted range of motion (ROM) within 3–6 months after primary total knee arthroplasty (TKA). However, there is little data on the outcomes of MUA with different types of anesthesia. We sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 413 neuraxial anesthesia) at a single institution from 2016–2019. Mean age was 62 years and 349 patients (64%) were female. Mean body mass index was 32 kg/m. 2. The mean time from primary TKA to MUA was 10 weeks. Mean pre-MUA ROM was similar between each group; mean pre-MUA extension was 4.2° (p=0.35) and mean pre-MUA flexion was 77° (p=0.56). Patient demographics were statistically similar between both groups. We compared immediate complications, including fracture, extensor mechanism disruptions, and wound complications, Visual analogue pain scores (VAS), length of stay (LOS), and immediate and 3 month follow-up ROM between these groups. Results. No patients in either group sustained an immediate post-MUA complication. Patients undergoing MUA with IV sedation had significantly higher day of MUA average VAS of 5.1 compared to 4.1 in the neuraxial group (p<0.001). The average LOS was shorter in patients that received IV sedation (9 hours) compared to neuraxial anesthesia (12 hours) (p=0.009). Immediate-post MUA ROM was 1° – 121° in the IV sedation group and 0.9° – 123° in the neuraxial anesthesia group (p=0.21). Three month follow-up ROM was 2° – 108° in the IV sedation group and 1.9° – 110° in the neuraxial anesthesia group. Conclusion. IV sedation and neuraxial anesthesia are both effective anesthetic methods for patients undergoing MUA after primary TKA with minimal perioperative differences. Surgeons and anesthesiologists should cater anesthetic technique to patient specific needs as the orthopedic outcomes are similar for both methods; however, IV sedation resulted in a shorter LOS

Aims. Multimodal infiltration of local anaesthetic provides effective control of pain in patients undergoing total knee arthroplasty (TKA). There is little information about the added benefits of posterior capsular infiltration (PCI) using different combinations of local anaesthetic agents. Our aim was to investigate the effectiveness of the control of pain using multimodal infiltration with and without infiltration of the posterior capsule of the knee. Patients and Methods. In a double-blind, randomised controlled trial of patients scheduled for unilateral primary TKA, 86 were assigned to be treated with multimodal infiltration with (Group I) or without (Group II) PCI. Routine associated analgesia included the use of bupivacaine, morphine, ketorolac and epinephrine. All patients had spinal anaesthesia and patient-controlled analgesia (PCA) post-operatively. A visual analogue scale (VAS) for pain and the use of morphine were recorded 24 hours post-operatively. Side effects of the infiltration, blood loss, and length of stay in hospital were recorded. Results. There were no statistically significant differences between the groups in relation to: VAS pain scores in the first 24 hours post-operatively (p = 0.693), the use of morphine in the PCA (p = 0.647), blood loss (p = 0.625), and length of stay (p = 0.17). There were no neurovascular complications in either group. Conclusion. The multimodal infiltration of local anaesthetic with infiltration of the posterior capsule did not provide significant added analgesic benefits or reduce the use of morphine after TKA. Multimodal infiltration is a satisfactory technique for the management of pain in these patients without the attendant risks of PCI. Cite this article: Bone Joint J 2017; 99-B:483–8

Introduction. We designed this study to compare 30-day complications and length of hospital stay between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal, epidural anesthesia, or Monitored Anesthesia Care (MAC, a combination of local anesthesia with sedation and analgesia provided by an anesthesiologist) with or without regional nerve blocks. Methods. We identified patients ≥18 years undergoing TKA between the years of 2006 and 2017 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). We collected patient demographics, anesthesia type, 30-day complications, length of operation and hospital stay from the database. We used multivariable regression to compare complications and length of stay (LOS) between anesthesia types, while adjusting for relevant covariables. Results. We identified 265,325 TKA patients. Of these, 91 (0.03%) underwent epidural anesthesia with a nerve block, while 1,855 (0.70%) underwent epidural anesthesia with no block, 12,800 (4.82%) underwent MAC with a block, 25,643 (9.66%) underwent MAC with no block, 13,575 (5.12%) underwent spinal anesthesia with a block, 80,803 (30.45%) underwent spinal anesthesia with no block, and 130,558 (49.21%) underwent general anesthesia. The rate of complications was not associated with the presence of a block, while the unadjusted LOS was significantly lower with the use of a block in patients treated with spinal anesthesia (2.54±2.07 vs. 2.84±2.25), epidural anesthesia (2.87±1.81 vs. 3.88± 4.67), and MAC (2.51±2.14 vs. 2.68±2.11), p<0.0001. The unadjusted rate of major complications was significantly lower in patients who underwent spinal anesthesia (2.10%), and MAC (1.91%) compared to general anesthesia (2.31%), p<0.0001. Similarly, the unadjusted rate of minor complications was significantly lower for patients treated with spinal anesthesia(1.86%) and MAC (1.78%) compared to general anesthesia (2.11%), p<0.0001. The unadjusted LOS was significantly longer in patients treated with epidural (3.83±4.58), compared to general (2.94±3.64) anesthesia, p<0.0001. In contrast, the unadjusted LOS was significantly lower for patients treated with spinal anesthesia (2.80±2.23), and MAC (2.62±2.12) compared to general anesthesia, p<0.0001. Following covariable adjustment, spinal anesthesia and MAC were associated with a 0.93 (0.87–0.98), and 0.84 (0.78–0.91), odds of major complications compared to general anesthesia. Similarly, spinal anesthesia and MAC were associated with a 0.92 (0.87–0.98) and 0.89 (0.82–0.97) odds of minor complications compared to general anesthesia. Following covariable adjustment, epidural anesthesia increased the LOS by 0.25 (0.27–0.28) days compared to general, while spinal anesthesia and MAC decreased the LOS by 0.04 (95%CI 0.05–0.04), and 0.10 (0.11–0.09) days, compared to general. In patients treated with spinal anesthesia, epidural anesthesia, and MAC, the use of a block was independently associated with a decreased LOS by 0.10 (0.12–0.90), 0.24 (0.39–0.09), and 0.07 (0.08–0.05). Conclusion. Patients who undergo TKA with spinal anesthetic, and MAC appear to have superior outcomes compared to those who undergo TKA with general anesthesia. In addition, the use of a regional nerve block appears to be independently associated with a shorter LOS in patients who undergo TKA with neuraxial (spinal and epidural) anesthetic, and MAC. For figures, tables, or references, please contact authors directly

The clinical results of bilateral total knee replacement staged at a one-week interval during a single hospital admission were compared with bilateral total knee replacements performed under the same anaesthetic and with bilateral total knee replacements performed during two separate admissions. The data were retrospectively reviewed. All operations had been performed by the same surgeon using the same design of prosthesis at a single institution. The operative time and length of stay for the one-week staged group were comparable with those of the separate admission group but longer than for the patients treated under one anaesthetic. There was a low rate of complications and good clinical outcome in all groups at a mean follow-up of four years (1 to 7.2). The group staged at a one-week interval had the least blood loss (p = 0.004). With appropriate patient selection, bilateral total knee replacement performed under a single anaesthetic, or staged at a one-week interval, is a safe and effective method to treat bilateral arthritis of the knee