The Journal of arthroplasty
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Randomized Controlled Trial
Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study.
In this prospective randomized study, patients undergoing total hip (THA) or knee arthroplasty (TKA) were randomized to either a study group receiving periarticular injections or a control group receiving patient-controlled analgesia with or without femoral nerve block (TKA patients). All patients received a comprehensive multimodal perioperative protocol. Pain, recovery of functional milestones, and overall satisfaction were assessed. ⋯ There was no significant difference in pain scores between the study and control groups in the TKA cohort. Both study groups demonstrated lower narcotic usage and side effects as well as improved early functional recovery. Periarticular injection with a multimodal protocol was shown to safely provide excellent pain control and functional recovery and can be substituted for conventional pain control modalities.
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Comparative Study
Observational study on intrathecal and peridural changes after routine spinal and epidural anesthesia in patients undergoing total joint arthroplasty.
Epidural bleeding from spinal anesthetics or epidural catheter placement is concerning, especially when anticoagulants are used. Little is known of the natural changes that occur subdurally or epidurally after each of these procedures. To describe the natural history and occurrence of bleeding that may result from these anesthetics with anticoagulants, we studied 16 joint arthroplasty patients who underwent spinal magnetic resonance imaging postoperatively. ⋯ No difference was observed between the anesthetics. Warfarin did not cause abnormal bleeding. Based on these observations, one should consider bleeding or peridural inflammation to be abnormal after spinal or epidural anesthesia.
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Ropivacaine blood and drain levels were measured in 20 hip and 15 total knee arthroplasties after intraoperative wound infiltration with 150 to 200 mL (360-400 mg) of ropivacaine, followed by a 48-hour intra-articular pain pump infusion of 1000 mg (knees) and 300 mg (hips) commencing 12 hours postoperatively. Concentrations were below 2 microg/mL over the first 12 hours before the pain pump increased levels. ⋯ Pain pump infusion produced some C(max) levels above 3.0 microg/mL, but there was no clinical evidence of toxicity. Wound drain amounts (0.53-26.69 mg) indicate reinfusion should be safe, although further study is needed to confirm this.
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Large-diameter femoral heads, which may reduce dislocation, are used without extensive in vivo research. Two studies were done to determine relative dislocation rates. Study 1 compared dislocation rates in primary total hip arthroplasties (THAs) using 28- or 38-mm heads. ⋯ Study 2 had 2 dislocations (0.4%). Dislocation rates in primary THA with 38-mm bearings via posterior approach are the same as 28-mm bearings via Hardinge approach. Metal-on-metal THA with 38 to 56 mm heads is also associated with low dislocation rates (0.4%) at short-term follow-up.
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Although airway obstruction secondary to cricoarytenoid arthritis is an infrequent perioperative complication of rheumatoid arthritis, it must be promptly recognized and appropriately managed to avoid fatal consequences. We report a case of cricoarytenoid dysfunction leading to acute respiratory insufficiency requiring tracheostomy in the immediate postoperative period after total knee arthroplasty in a patient with severe rheumatoid arthritis.