Results from this pilot feasibility study suggest that tDCS may be able to reduce post-TKA opioid requirements. Although these results are preliminary, the data support further research in the area of adjunctive cortical stimulation in the management of postsurgical pain.

Background Pain is often a complaint that precedes total knee arthroplasty (TKA), however the procedure itself is associated with considerable post-operative pain lasting days to weeks which can predict longer-term surgical outcomes. Previously, we reported significant opioid-sparing effects of motor cortex transcranial direct current stimulation from a single-blind trial. In the present study, we used double-blind methodology to compare motor cortex tDCS and prefrontal cortex tDCS to both sham and active-control (active electrodes over non-pain modulating brain areas) tDCS. Methods 58 patients undergoing unilateral TKA were randomly assigned to receive 4 20-minute sessions (a total of 80 minutes) of tDCS (2mA) post-surgery with electrodes placed to create 4 groups: 1) MOTOR (n=14); anode-motor/cathode-right prefrontal, 2) PREFRONTAL (n=16); anode-left-prefrontal/cathode-right-sensory, 3) ACTIVE-CONTROL (n=15); anode-left-temporal-occipital junction/cathode-medial-anterior-premotor-area, and 4) SHAM (n=13); 0mA-current stimulation using placements 1 or 2. Patient controlled analgesia (PCA; hydromorphone) use was tracked during the ∼72-hours post-surgery. Results Patients in the sham group and the active-control group used 15.4mg (SD=14.1) and 16.0mg (SD=9.7) of PCA hydromorphone respectively. There was no difference between the slopes of the cumulative PCA usage curves between these two groups (p=.25; ns). Patients in the prefrontal tDCS group used an average of 11.7mg (SD=5.0) of PCA hydromporhone, and the slope of the cumulative PCA usage curve was significantly lower than sham (p<.0001). However, patients in the motor tDCS group used an average of 19.6mg (SD=11.9) hydromorphone and the slope of the PCA use curve was significantly higher than sham (p<.0001). Conclusions Results from this double-blind cortical-target-optimization study suggest that anodal transcranial direct current stimulation (tDCS) over the left prefrontal cortex may be a reasonable approach to reducing post-TKA opioid requirements. Given the unexpected finding that motor cortex failed to produce an opioid sparing effect in this follow-up trial, further research in the area of post-operative cortical stimulation is still needed.

No abstract

Background: Fungal prosthetic joint infections (PJIs) are rare and often associated with poor outcome; however, risk factors are not well described. Methods: This was a retrospective case control study among all patients with PJIs from 2006-2016 at two major academic centers. Each fungal PJI case was matched 1:1 with a bacterial PJI control by joint (hip, knee, shoulder) and year of diagnosis. We compared demographics, comorbidities, and clinical characteristics between cases and controls using chi square/Fisher's exact or Wilcoxon rank sum test. Independent risk factors were identified with multivariable logistic regression. Results: Forty-one fungal PJIs occurred over the study and 61% were due to Candida albicans. The hip was involved in 51.2% of cases, followed by the knee (46.3%). Compared to bacterial PJI, fungal PJI cases were more likely to have received antibiotics within the previous 3 months (70.7% vs 34%, P=.001), wound drainage lasting >5 days (48% vs 9%, P=.0002), had a lower median CRP (2.95 mg/dl vs 5.99, P=.013) and synovial fluid white blood cell count (13,953 cells/mm 3 vs 33,198, P=.007), and a higher proportion of prior two-stage exchanges (82.9% vs 53.6%, P=.008). After controlling for center, prolonged wound drainage (OR, 7.3; 95% CI,) and recent antibiotics (OR, 3.4; 95% CI, 1.2-9.3) were significantly associated with fungal PJI. Conclusion: In our study, Candida albicans was the most common species in fungal PJIs and prolonged wound drainage and recent antibiotics were independent risk factors. These clinical characteristics may help providers anticipate fungal PJI and adjust management strategies.

No abstract

No abstract

No abstract

No abstract