Clinical orthopaedics and related research
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Clin. Orthop. Relat. Res. · Jun 2009
Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center.
Improvements in pain management techniques in the last decade have had a major impact on the practice of total hip and knee arthroplasty (THA and TKA). Although there are a number of treatment options for postoperative pain, a gold standard has not been established. However, there appears to be a shift towards multimodal approaches using regional anesthesia to minimize narcotic consumption and to avoid narcotic-related side effects. Over the last 10 years, we have used intravenous patient-controlled analgesia (PCA), femoral nerve block (FNB), and continuous epidural infusions for 24 and 48 hours with and without FNB. Unfortunately, all of these techniques had shortcomings, not the least of which was suboptimal pain control and unwanted side effects. Our practice has currently evolved to using a multimodal protocol that emphasizes local periarticular injections while minimizing the use of parenteral narcotics. Multimodal protocols after THA and TKA have been a substantial advance; they provide better pain control and patient satisfaction, lower overall narcotic consumption, reduce hospital stay, and improve function while minimizing complications. Although no pain protocol is ideal, it is clear that patients should have optimum pain control after TKA and THA for enhanced satisfaction and function. ⋯ Level V, expert opinion. See the Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Jun 2009
Randomized Controlled TrialPerioperative dexamethasone does not affect functional outcome in total hip arthroplasty.
Current trends in orthopaedic surgery have explored different forms of adjuvant treatments to minimize postoperative pain and the risk of nausea and vomiting. A small single preoperative dose of dexamethasone, as part of a comprehensive multimodal analgesic regimen in low-risk patients undergoing total hip arthroplasty (THA), provides antiemetic and opioid-sparing effects but the longer-term effects on pain, complications, or function are not known. We therefore asked whether such a routine would affect longer-term pain, complications, or function. Fifty patients undergoing elective primary THA using spinal anesthesia were initially randomized to receive either dexamethasone (40 mg intravenous) or saline placebo. The patients, anesthesiologists, nurses, and research coordinators were blinded to the study arms. The functional outcome was measured using the Harris hip score. Outcomes were assessed 6 weeks and 1 year postoperatively. We observed no difference in resting pain between the two groups at either time period. Both groups had similar functional outcome scores for the total Harris hip score and individual scoring items at each followup interval. There were no wound complications, deep infections, or osteonecrosis in the contralateral hip at 1-year followup. We recommend the addition of a small single preoperative dose of dexamethasone to a comprehensive multimodal analgesic regimen in low-risk patients given its immediate antiemetic and opioid-sparing effects, and absence of subsequent effects. ⋯ Level II, therapeutic study (prospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Jun 2009
Newer anesthesia and rehabilitation protocols enable outpatient hip replacement in selected patients.
Advancements in the surgical approach, anesthetic technique, and the initiation of rapid rehabilitation protocols have decreased the duration of hospitalization and subsequent length of recovery following elective total hip arthroplasty. We assessed the feasibility and safety of outpatient total hip arthroplasty in 150 consecutive patients. A comprehensive perioperative anesthesia and rehabilitation protocol including preoperative teaching, regional anesthesia, and preemptive oral analgesia and antiemetic therapy was implemented around a minimally invasive surgical technique. A rapid rehabilitation pathway was started immediately after surgery and patients had the option of being discharged to home the day of surgery if standard discharge criteria were met. All 150 patients were discharged to home the day of surgery, at which time 131 patients were able to walk without assistive devices. Thirty-eight patients required some additional intervention outside the pathway to resolve nausea, hypotension, or sedation prior to discharge. There were no readmissions for pain, nausea, or hypotension yet there was one readmission for fracture and nine emergency room evaluations in the three month perioperative period. This anesthetic and rehabilitation protocol allowed outpatient total hip arthroplasty to be routinely performed in these consecutive patients undergoing primary total hip arthroplasty. With current reimbursement approaches the modest savings to the hospital in length of stay may be outweighed by the additional costs of personnel, thereby making this outpatient system more expensive to implement. ⋯ Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Jun 2009
Genu valgum in Legg-Calvé-Perthes disease treated with femoral varus osteotomy.
Femoral varus osteotomy is one of the most common treatments for patients with symptomatic Legg-Calvé-Perthes disease with more severe deformities. We hypothesized knee valgus alignment at maturity in patients with Legg-Calvé-Perthes disease is an effect of the disease and not an effect of femoral varus osteotomy. We retrospectively compared matched groups of 28 patients with and without femoral varus osteotomy. The two groups were similar with respect to age at onset and classification of Herring et al. The distribution of valgus alignment among patients who had surgery and patients who did not have surgery was assessed at maturity and was similar between the operative and nonoperative groups. The data suggest valgus malalignment (genu valgum) is not a side effect of femoral varus osteotomy in patients with Legg-Calvé-Perthes disease, but rather an effect of the disease. ⋯ Level III, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Jun 2009
The feasibility and perioperative complications of outpatient knee arthroplasty.
The duration of hospitalization and subsequent length of recovery after elective knee arthroplasty have decreased. We hypothesized same-day discharge following either a unicompartmental (UKA) or total knee arthroplasty (TKA) in an unselected group of patients would not result in a higher perioperative complication rate than standard-length hospitalization when following a comprehensive perioperative clinical pathway, including preoperative teaching, regional anesthesia, preemptive oral analgesia, preemptive antiemetics, and a rapid rehabilitation protocol. We prospectively followed 111 of all 121 patients who had primary knee arthroplasty completed by noon and who agreed to be followed prospectively; 25 had UKA and 86 TKA. Of the 111 patients, 104 (94%, 24 with UKA and 80 with TKA) met discharge criteria and were discharged directly to home the day of surgery. Nausea requiring additional treatment before discharge was the most common reason for a delay in discharge. There were four (3.6%) readmissions (all with TKA) and one emergency room visit without readmission (in a patient with a TKA) within the first week after surgery, while there were four subsequent readmissions (3.6%) and one additional emergency room visit without readmission within three months of surgery, all among patients undergoing TKA. There were no deaths, cardiac events, or pulmonary complications during this study. Outpatient knee arthroplasty surgery is feasible in a large percentage of patients yet early readmissions may be decreased with a prolonged hospitalization. ⋯ Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.