INTRODUCTION. Tranexamic Acid (TA) has been shown to decrease peri-operative bleeding in primary Total Knee Replacement (TKR) surgery. There are still concerns with regards to the increased risk of thromboembolic events with the use of TA. The aim of this study was to assess whether the use of pre-operative TA increased the incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in TKR. METHODS. Patients who underwent primary TKR between August 2007 and August 2009 were identified from the databases of three surgeons within the lower limb arthroplasty unit. A retrospective case notes analysis was performed. DVT was diagnosed on Duplex Ultrasound Scan and PE on CT Pulmonary Angiogram. A positive result was a diagnosis of DVT or PE within 3 months of surgery. RESULTS. 322 patients underwent primary TKR over the 2 year period. 131 patients received TA pre-operatively. 191 patients did not receive TA prior to surgery. A total of 4 (3.1%) patients who received TA were diagnosed with either a DVT (2) or PE (2) post operatively. In those patients not receiving TA, 6 had a DVT and 2 had a PE, a total of 8 (4.2%). CONCLUSION. Pre-operative use of Tranexamic Acid in primary Total Knee Replacement does not increase the incidence of DVT and PE

Purpose. The purpose of this study were to investigate whether there is an association between the preoperative body mass index in total knee replacement patients and the effect three to five years postoperative. Method. 197 patients who had undergone primary total knee replacement in the period 1.1.2005–31.12.2006 participated in a three-five years of follow-up study. Outcome measures were self-rated health (SF-36), which consists of eight strands and two component scores, physical component score and mental component scores and the Knee Society rating system (KSS) (knee score and function scores), and improvement of the two KSS scores from baseline to follow-up. Results. With Ordinal logistic regression (adjusted for gender, age, basic disease and surgical procedure) were found statistically significant association between body mass index and nine of the fourteen outcome measures. For all outcome measures were found OR > 1. With a difference in body mass index of 1kg/m2 increases the risk of lower scores from a minimum of 2% OR 1.02 (0.97–1.07) p=0.5 (mental component score) to maximum 14% OR 1.14 (1.08–1.21) p <0.001 (KSS function score). With a difference in body mass index on 5kg/m2 increases the risk of lower scores from a minimum of 9% OR 1.09 (mental components scores) to a maximum of 96% OR 1.96 (KSS function scores). With a difference in body mass index of 10kg/m2 rises risk of worse score with minimum 19% OR 1.19 (mental component score) to a maximum of 284% OR 3.84 (KSS function score). Conclusion. There is a clear association between body mass index and efficacy 3–5 years following primary total knee replacement. More than half of the Outcome measures were statistically significant and the outcomes that were not statistically significant are clinically interesting. High body mass index increases the risk of poor outcome after total knee Arthroplasty

Background. Randomized, controlled trials (RCTs) are generally accepted as the “gold standard” for the provision of the most unbiased measures of the efficacy of interventions but are often criticized for the lack of external validity. We assessed the external validity of a RCT examining the efficacy of local infiltration analgesia (LIA) compared with continuous epidural infusion after total knee arthroplasty (TKA). Methods. During a one-year period, all patients consecutively admitted for elective, unilateral, primary TKA were identified as potential participants. All underwent eligibility screening to determine who were eligible for participation in a randomized controlled trial. We investigated the distribution of preoperative characteristics and postoperative variables among excluded patients, non-consenters, and enrolled and randomized participants. Results. In all 157 patients were identified as potential participants. Only 49 patients (31%) were enrolled and randomized. A significant difference was found in both preoperative characteristics and clinical outcome variables. Non-participants were less healthy and needed more help from the home care service than did participants. Furthermore, they were hospitalized longer. Interpretation. Our findings demonstrate the importance of reporting the results of RCTs in a way that allows clinicians to judge to whom the results can reasonably be applied

The prevalence of Parkinson's disease (PD) is expected to rise however reports of the outcomes of total knee arthroplasty (TKA) in patients with PD in the literature are sparse. We present the first study to compare short to medium term outcomes of TKA in patients with and without PD.

We performed a retrospective analysis of data from our regional arthroplasty database. In our PD group 32 TKAs were implanted. In our age-matched control group 33 TKAs were implanted. Mean age at operation was 73 years and the primary indication was osteoarthritis in both groups.

Data was collected pre-operatively and at routine 1, 3 and 5 year follow-up attendances. Median in-patient stay was comparable in both groups (P=0.714). Pre-operatively, there were no between-group differences in range of movement, Knee Society Function Score (KSFS), Knee Society Score (KSS) or Pain score taken as an independent variable (P=0.108, 0.079, 0.478 and 0.496). KSS improved in both groups post-operatively with no significant between-group differences (P=0.707). Improvement was maintained to Year 5 (median 30 points pre-operatively and 91 points at Year 5 in PD group). Pain score also improved in both groups. There was no functional improvement following TKA in the PD group. In the controls, an increase in KSFS at Year 1 was followed by a return to pre-operative values at Year 5. Complications in the PD group included 1 case of bilateral quadriceps tendon avulsion and 1 dislocation requiring revision.

Patients with PD benefit from excellent pain relief following TKA for at least 5 years after surgery.

There is conflicting data from small retrospective studies as to whether pre-operative mental health influences the outcome of total knee replacement (TKR).

We assessed the effect of mental disability upon the outcome of TKR and whether mental health improves post-operatively. During a three year period patients undergoing TKR for primary osteoarthritis at the study centre had prospectively outcome data recorded (n=962). Pre-operative and one year short-form (SF) 12 scores and Oxford knee scores (OKS) were obtained. The mental component of the SF-12 was stratified into four groups according to level of mental disability (none ≥50, mild 40to49, moderate 30to39, severe <30). Ethical approval was obtained (11/AL/0079).

Patients with any degree of mental disability had a significantly greater subjective physical disability according to the SF-12 (p=0.06) and OKS (p<0.001). Although the improvement in the disease specific score (OKS) was not affected by a patients mental health (p=0.33). In contrast the improvement of the global physical health (SF-12) for patients with a mental disability did not improve to the same magnitude (p<0.001). However, patients with mental disability, of any degree, had a significant improvement in their mental health post-operatively (p<0.0001). Despite the similar improvement in the disease specific scores and improvement in their mental health, patients with mental disability were significantly more likely to be dissatisfied with their TKR at one year (p=0.001).

TKR for patients with poor mental health benefit from improvement in their mental health and in their knee function, but do have a higher rate of dissatisfaction.

Revision Total Knee Arthroplasty (rTKA) is predicted to increase by more than 600% between 2005 and 2030. The survivorship of primary TKA has been extensively investigated, however more granular information on the risks of rTKA is needed. The aim of the study was to investigate the incidence of re-revision TKA, with explanatory variables of time from primary to revision, and indication (aseptic vs septic). Secondary aim was to investigate mortality. This is an analysis of the Scottish Arthroplasty Project data set, a national audit prospectively recording data on all joint replacements performed in Scotland. The period from 2000 to 2019 was studied. 4723 patients underwent revision TKA. The relationship between time from primary to revision TKA and 2nd revision was significant (p<0.001), with increasing time lowering probability of re-revision (OR 0.99 95% CI 0.987 to 0.993). There was no significant association in time to first revision on time from 1st revision to re-revision (p>0.05). Overall mortality for all patients was 32% at 10 years (95% CI 31-34), Time from primary TKA to revision TKA had a significant effect on mortality: p=0.004 OR 1.03 (1.01-1.05). Septic revisions had a reduced mortality compared to aseptic, OR 0.95 (0.71-1.25) however this was not significant (p=0.69). This is the first study to demonstrate time from primary TKA to revision TKA having a significant effect on probability of re-revision TKA. Furthermore the study suggests mortality is increased with increasing time from primary procedure to revision, however decreased if the indication is septic rather than aseptic

The primary aim was to assess whether patients waiting 6-months or more for a total hip (THA) or knee (KA) arthroplasty had a deterioration in their health-related quality of life (HRQoL). Secondary aims were to assess change in level of frailty and the number living in a state worse than death (WTD). Eight-six patients waiting for a primary TKA or KA for more than 6-months were selected at random from waiting lists in three centres. Patient demographics, waiting time, EuroQol 5-dimension (EQ-5D) and visual analogue scores (EQ-VAS), Rockwood clinical frailty score (CFS) and SF-36 subjective change in HRQoL were recorded at the time of and for a timepoint 6-months prior to assessment. The study was powered to the EQ-5D (primary measure of HRQoL). There were 40 male and 46 female patients with a mean age of 68 (33 to 91) years; 65 patients were awaiting a THA and 21 a TKA. The mean waiting time was 372 (226 to 749) days. The EQ-5D index deteriorated by 0.222 (95%CI 0.164 to 0.280, p<0.001). The EQ-VAS also deteriorated by 10.8 (95%CI 7.5 to 14.0, p<0.001). CFS progressed from a median of 3 to 4 (p<0.001). The number of patients WTD increased from seven to 22 (p<0.001). Thirty-one(36%) patients felt their HRQoL was much worse and 28 (33%) felt it was somewhat worse. Patients waiting more than 6-months had a clinically significant deterioration in their HRQoL and demonstrated increasing level of frailty with more than a quarter living in a health state WTD

Prosthetic joint infections provide complex management, due to often-difficult diagnosis, need for multiple surgeries and increased technical and financial requirements. “2 in 1” single stage approaches have been advocated due to reduction in risks, costs and complications. This study aimed to investigate the results of single stage revision using metaphyseal sleeves for infected primary Total Knee Replacement (TKR). Prospective data was collected on all patients presenting with an infected primary TKR over an 8-year period (2009–17). All revision procedures were undertaken in a single stage using metaphyseal sleeves. 26 patients were included, 2 of which had previously failed 2 stage revision and 3 failed DAIR procedures. Mean age was 72.5. Mean BMI was 33.4. Median ASA 2. Mean time to revision was 3.5 years range 3 months to 12 years. Six patients had actively discharging sinuses at the time of surgery. Only 4 of the 26 patients had no positive microbiological cultures from deep tissue samples or joint aspirates. Only one patient has a recurrence of infection. This patient did not require further surgery and is treated on long term antibiotic suppression and is systemically well. There were statistically significant improvements in both the pain and function component of AKSS scores. There was no significant improvement in flexion, however mean extension and total range of movement both showed statistically significant improvements. Using Metaphyseal sleeves in single stage revision for infected TKR are safe and lead to an improvement in pain, function and have excellent efficacy for eradication of infection

Aims

Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

Successful return to work (RTW) is a crucial outcome after primary total knee arthroplasty (TKA) in patients under 65 years old. We aimed to determine whether TKA facilitated RTW in patients <65 years, whose intention was to return preoperatively. We prospectively assessed 106 TKA patients under 65 years over a 1 year period both preoperatively and at 1 year following surgery. Patient demographics were collected including Oxford knee score, Oxford-APQ, VAS pain/health scores and EQ-5D. A novel questionnaire was distributed to delineate pre-operative employment status and post-operative intentions. This included questions on nature of pre and post-operative occupation, whether joint disease affected their ability to work and details of retirement plans and how this was affected by their knee. 69 patients intended to return to work following their TKA. Following arthroplasty, 57/69 patients (82.6%) returned to work at a mean of 16.4 weeks (SD 16.6). Univariate analysis showed significant factors facilitating RTW included, pre-operative oxford knee score, pre-operative Oxford-APQ score and pre-operative EQ-5D score. These were not predictive on multivariate analysis. This study finds that TKA facilitates return to work in 83% of those who intend to return to work following their surgery. This could have significant positive and health and financial cost implications for the individual, health system and society

Background. Improving positioning and alignment by the use of computer assisted surgery (CAS) might improve longevity and function in total knee replacements. This study evaluates the short term results of computer navigated knee replacements based on data from a national register. Patients and Methods. Primary total knee replacements without patella resurfacing, reported to the Norwegian Arthroplasty Register during the years 2005–2008, were evaluated. The five most common implants and the three most common navigation systems were selected. Cemented, uncemented and hybrid knees were included. With the risk for revision due to any cause as the primary end-point, 1465 computer navigated knee replacements (CAS) were evaluated against 8214 conventionally operated knee replacements (CON). Kaplan-Meier survival analysis and Cox regression analysis with adjustment for age, sex, prosthesis brand, fixation method, previous knee surgery, preoperative diagnosis and ASA category were used. Results. Kaplan-Meier estimated survival at two years was 97.9% (95% CI: 97.5–98.3) in the CON group and 96.4% (95% CI: 95.0–97.8) in the CAS group. The adjusted Cox regression analysis showed a statistically significantly higher risk for revision in the CAS group (relative risk = 1.7, 95% CI: 1.1–2.5, p = 0.019). The LCS complete knees had a significantly higher risk for revision with CAS, compared to CON (relative risk = 2.1 (95% CI 1.3–3.4, p = 0.004)). Mean operating time was 15 minutes longer in the CAS group. Conclusion. Survivorship at two years of computer navigated primary total knee replacements was inferior compared to conventionally operated knees. Therefore, an extensive use of CAS in primary total knee replacement surgery cannot be encouraged until proven superior in long term register studies and clinical trials

Background. There are few studies of total knee replacements with cemented tibia and uncemented femur (hybrid). Previous studies have not shown any difference in revision rate between different fixation methods, but these studies had few hybrid prostheses. This study evaluates the results of hybrid knee replacements based on data from the Norwegian Arthroplasty Register (NAR). Patients and Methods. Primary total knee replacements without patella resurfacing, reported to the NAR during the years 1999–2009, were evaluated. Hinged-, posterior stabilized- and tumor prostheses were excluded. LCS- and Profix prostheses with conforming plus bearing were included. With the risk for revision at any cause as the primary end-point, 2945 hybrid knee replacements (HKR) were evaluated against 20838 cemented knee replacements (CKR). Kaplan-Meier survival analysis and Cox regression analysis with adjustment for age, sex and preoperative diagnosis were used. Results. Kaplan-Meier estimated survival at 8 years was 94.0% (95% CI: 93.6–94.4) in the CKR group and 97.0% (95% CI: 96.0–98.0) in the HKR group. The HKR group was made op of three brands of prosthesis, LCS, LCS-complete and Profix. Profix was the only brand with a statistically significant difference between cemented and hybrid fixation. Kaplan-Meier estimated survival at 8 years was 97.7% (95% CI: 96.7–98.7) in hybrid Profix group (HPG) and 95.5% (95% CI: 94.7–96.3) in the cemented Profix group (CPG). The adjusted Cox regression analysis showed a statistically significantly lower risk for revision in the HPG group (relative risk=0.44, 95% CI: 0.39–0.59, p<0.001). Mean operating time was 15 minutes longer in the CKR group. Conclusion. Survivorship at 8 years of the hybrid primary total knee replacements was the same or superior compared to cemented total knee replacements depending on prosthesis brand Hybrid fixation seems to be a safe alternative to cemented fixation in total knee replacement surgery

Introduction. There has been renewed interest in the unicompartmental knee arthroplasty with reports of good long term outcomes. Advantages over a more extensive knee replacement include: preservation of bone stock, retention of both cruciate ligaments, preservation of other compartments and better knee kinematics. However, a number of authors have commented on the problem of osseous defects requiring technically difficult revision surgery. Furthermore, a number of recent national register studies have shown inferior survivorship when compared to total knee arthroplasty. The purpose of this study was to review the cases of our patients who had a revision total knee arthroplasty for failed unicompartmental knee arthroplasty. To determine the reason for failure, describe the technical difficulties during revision surgery and record the clinical outcomes of the revision arthroplasties. Methods. Between 2003 and 2009 our institute performed thirty three revisions of a unicompartmental knee arthroplasty on thirty two patients. The time to revision surgery ranged from 2 months to 159 months with a median of 19 months. Details of the operations and complications were taken form case notes. Patient assessment included range of motion, need for walking aids and the functional status of the affected knee in the form of the Oxford knee score questionnaire. Results. The reasons for failure were aseptic loosening of tibial component, persistent pain, dislocated meniscus, mal-alignment and osteoarthritis in another compartment. Of the 33 revision knee arthroplasties 18 required additional intra-operative constructs. 11 knees required a long tibial stem while 1 required a long femoral stem. 10 knees required medial wedge augmentation and bone graft was used in 6. Mean 1 year Oxford knee scores for failed unicompartmental knee replacements was 29 compared to 39 for primary total knee replacements performed at the same institute. Of the revision knee replacements 2 required further revision due to infection and loosening. Conclusion. From the evidence of our group of failed unicompartmental knee replacements, revision surgery is technically difficult and often requires intra-operative constructs. Clinical outcome of revision total knee arthroplasty following failed unicompartmental knee arthroplasty is not comparable to primary total knee arthroplasty

Introduction. Plate fixation for distal femoral fractures is a commonly used method of fracture stabilisation. Many orthopaedic surgeons traditionally do not allow their patients to weight bear for the first 6 weeks after surgery, fearing of loss of fracture reduction and metalwork failure. The aim of this study is to investigate whether the post-operative weight bearing status after plate fixation influences the outcome in terms of loss of reduction and metalwork failure. Materials & Methods. A retrospective data collection from all patients who treated in our hospital surgically for distal femoral fractures, from January 2015 until June 2017. Inclusion criteria were the operative treatment of these fractures with plate fixation. Patients who were treated with retrograde nail, primary total knee replacement or screw fixation were excluded from the study. Patient, injury and surgery demographic data was collected. The immediate post-operative weight bearing status of these patients was noted. Weight bearing status was divided into two groups – Group 1 (Non and touch weight bear – the non-weight bearing group) and Group 2 (Weight bear as tolerated / Full weight bear – the weight bearing group). Radiological data about fracture displacement or metalwork failure was collected at the six weeks and three months follow up after the operation, using a standardised measurement for displacement performed independently by two authors (EI, TA). Results. Of 70 patients, a total of 51 fractures treated with plate fixation were included to the study. The mean age of the cohort was 64.3 ±20.7 years with the majority of the patients being female (63%). Most of the patients (40%) had a complete articular distal femoral fracture, AO Type 33C. Thirty-nine patients (76%) were treated with one lateral distal femoral plate. The total number of the patients in group 1 was 32 (68%); with 17 patients (32%) in group 2. The weight bearing status did not correlate with the fracture type or the fixation type (p>0.05). None of the 6 weeks follow up radiographs revealed fracture displacement in both study groups. Four of the patients from the non-weight bearing group had >1mm displacement at the 3 months' follow-up radiographs. Fisher's exact test revealed no statistically significant difference between the two study groups in both follow-up time points (p=0.55). Two of the patients in the non-weight bearing group had their plate broken at the 3 months follow up and required revision fixation. Conclusion. By reviewing the outcomes in terms of fracture displacement and metalwork failure following plate fixation of distal femoral fractures, early weight bearing of these patients do not jeopardise the outcome of the operation

Introduction. Stiffness of the knee after total knee arthroplasty (TKA) impairs knee function and reduces patient satisfaction. Limited preoperative range of motion (ROM) and a diagnosis of osteoarthritis seem to be associated with postoperative stiffness, and medical comorbidities such as diabetes mellitus have been discussed as predisposing factors. The present study was undertaken in order to analyse both patient-related and surgical factors that could be associated with the need for mobilization under anaesthesia (MUA) after TKA. Methods. We designed a case-control-study and extracted the study population from our local arthroplasty register. We identified all patients in our register that required MUA following primary TKA (n=35) and then randomly selected 4 control patients for each case of MUA. Incomplete medical records resulted in the exclusion of 18 patients, leaving 157 patients. Univariate analysis was used in order to investigate differences between the two groups with respect to demographics, pre- and postoperative ROM, medical or psychiatric comorbidities, and the type of implant. Variables with a proposed influence on outcome were entered into a binary logistic regression model, and risk ratios (RR) were calculated with 95% confidence intervals (CI). Results. Regression analysis showed that age at operation, the presence of chronic obstructive lung disease (COLD), and preoperative flexion significantly affected outcome: Increasing age decreased the risk for needing MUA with a RR of 0.88 (CI 0.82–0.94, p<0.001) per year. Patients with COLD had significantly higher risk of needing MUA with a RR of 9.82 (CI 1.84–52.3, p=0.007). Impaired preoperative flexion was an important predictor of postoperative stiffness with a RR of 0.97 (CI 0.95–0.99, p=0.027), implicating that the risk for MUA decreased by approximately 3% for each additional degree of flexion. Gender, BMI, cardiovascular comorbidity, the presence of rheumatoid arthritis, diabetes mellitus, previous knee injury, and the type of implant did not significantly affect the risk for MUA. In univariate analysis, patients requiring MUA had significantly lower knee flexion at discharge than control patients (78° vs. 61°, p<0.001). Interpretation. We conclude that the presence of COLD, impaired preoperative knee flexion, and younger age increase the risk for needing MUA after primary TKA. The finding that COLD increases the risk for MUA is novel: It is known that patients with COLD have higher systemic levels of inflammatory mediators, and we are tempted to speculate that postoperative arthrofibrosis could be a result of enhanced systemic inflammatory activity. In our hands, the choice of implant and comorbidities other than COLD were not associated with an increased risk for MUA

Tranexamic Acid (TA) has been shown to reduce transfusion rates in Total Knee Replacement (TKR) without complication. In our unit it was added to our routine enhanced recovery protocol. No other changes were made to the protocol at this time and as such we sought to examine the effects of TA on wound complication and transfusion rate. All patients undergoing primary TKR over a 12 month period were identified. Notes and online records were reviewed to collate demographics, length of stay, use of TA, thromboprophylaxis, blood transfusion, wound complications and haemoglobin levels. All patients received a Columbus navigated TKR with a tourniquet. Only patients who received 14 days of Dalteparin for thromboprophylaxis were included. 124 patients were included, 72 receiving TA and 52 not. Mean age was 70. Four patients required a blood transfusion all of whom did not receive TA (p = 0.029). Mean change in Hb was 22 without TA and 21 with (p = 0.859). Mean length of stay was 6.83 days without Tranexamic Acid and 5.15 with (p < 0.001). 15% of patients (n=11) of the TA group had a wound complication, with 40% of patients (n=21) in the non TA group (p = 0.003). There was one ultrasound confirmed DVT (non TA group). No patients were diagnosed with pulmonary embolus. In our unit we have demonstrated a significantly lower transfusion rate, wound complication rate and length of stay, without any significant increase in thromboembolic disease with the use of TA in TKR

By the end of training, every registrar is expected to demonstrate proficiency in total knee replacement (TKR). It is unclear whether functional outcomes for knee arthroplasty performed by training grade doctors under supervision of a consultant have equivalent functional outcomes to those performed by consultants. This study investigated the functional outcomes following TKR in patients operated on by a supervised orthopaedic trainee compared to a consultant orthopaedic surgeon. Patients undergoing surgery by a consultant (n=491) or by a trainee under supervision (n=145) between 2003 and 2006 were included. There was a single implant, approach and postoperative rehabilitation regime. Patients were reviewed eighteen months, three years and five years postoperatively. There were no significant differences in preoperative patient characteristics between the groups. There was no difference in length of stay or transfusion or tourniquet time. Both consultant (p<0.001) and trainee (p<0.001) groups showed significant improvement in AKSK and AKSF scores between preoperative and 18 month review and there was no difference in the magnitude of observed improvement between groups (AKSK p=0.853; AKSF p=0.970). There were no significant differences in either score between the groups preoperatively or at any review point postoperatively. At five years postoperative, both groups had a median OKS of 34 (p=0.921). This is the largest reported series of outcomes following primary TKR examining functional outcome linked with grade of surgeon. It shows that a supervised trainee will achieve comparable functional outcomes at up to 5 years post operatively

This study assessed whether patient satisfaction with their hospital stay influences the early outcome of total knee replacement (TKR). During a five year period patients undergoing primary TKR at the study centre had prospectively outcome data recorded (n=2264). Patients with depression (p=0.04) and worse mental wellbeing (p<0.001), according to the short form (SF)-12, were more likely to be dissatisfied with their hospital stay. Decreasing level of satisfaction with their hospital stay was associated with a significantly worse post-operative OKS (p<0.001) and SF-12 score (p<0.001). Multivariable regression analysis confirmed that the patients perceived level of satisfaction with their hospital stay was an independent predictor of change in the OKS (p<0.001) and SF-12 score (p<0.001) after adjusting for confounding variables. Patient satisfaction with their TKR was significantly influenced by their hospital experience, decreasing from 96% in those with an excellent experience to 42% in those with a poor experience. Food, staff/care, and the hospital environment were the most frequent reasons of why patients rated their hospital experience as fair or poor. A patient's perception of their inpatient hospital experience after surgery is an important modifiable predictor of early functional outcome and satisfaction with TKR

Anterior knee pain post Total knee Replacement (TKR) has been reported to be as high as 49%. The source is poorly understood; both the peripatellar soft tissues and the infrapatellar fat pad have been implicated. Immunohistochemical studies demonstrate hyperinnervation of the peripatellar soft tissues. In theory circumferential electrocautery denervates the patella. However there is little evidence that this practice translates into improved clinical outcomes. This study aimed to find the effect on clinical outcome, of intraoperative circumpatellar electrocautery in patients undergoing TKR. 200 patients undergoing primary TKR were randomised to circumferential circumpatellar electrocautery or nothing. Patients were assessed for Visual (VAS) for anterior knee pain and Oxford Knee Score (OKS) preoperatively, 3 months, 6 months and 1 year post-procedure. Patients and assessors were blinded to treatment allocation until the end of the study. There were 91 patients in the electrocautery group and 94 controls. The mean VAS improvement from pre-op to one year was 3.8 in both groups. The mean improvement in OKS was 16.6 points in the control and 17.7 in the electrocautery group (p= 0.40). There were no significant differences between the two groups in terms of VAS or OKS at any other time. Although previous studies have conflicting outcomes, to our knowledge this is the first prospective randomised controlled blinded trial of significant power, to evaluate the effect of peripatellar diathermy in TKR. We conclude that denervation electrocautery of the patella makes no difference to the clinical outcomes of TKR

Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain. This impedes early mobilization and delays hospital discharge. A prospective audit of 1081 patients undergoing primary TKA during 2008 was completed. All patients followed a programme including preoperative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, postoperative high volume ropivacaine boluses with an intra-articular catheter and early mobilization. Primary outcome measure was length of stay. Secondary outcomes were verbal analogue pain scores on movement, time to mobilization, nausea and vomiting scores, urinary catheterization for retention, need for rescue analgesia, range of motion at discharge and six weeks postoperatively. The median day of discharge was postoperative day four. Median pain score on mobilization was three for first postoperative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterization rate was 6.9%. Rescue analgesia was required in 5% of cases. The median day of discharge was postoperative day four. Median range of motion was 85° on discharge and 93° at six weeks postoperatively. This comprehensive care plan provides satisfactory postoperative analgesia allowing early safe ambulation and discharge