Background The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI). Methods This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M 0 ), ITM 0.1 mg (M 1 ), and ITM 0.2 mg (M 2 ). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared. Results The trial enrolled 102 patients: M 0 (n = 32), M 1 (n = 35), and M 2 (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M 1 and M 2 did not differ significantly within the first 24 hours and were significantly lower than those in group M 0 . Nausea and vomiting were observed more frequently 4 hours postoperatively in M 2 than in groups M 1 and M 0 (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09). Conclusion Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.
Background Debridement, antibiotics, and implant retention (DAIR) is the recommended treatment for acute hematogenous periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, DAIR is associated with a high percentage of unsuccessful outcomes. Since 2007, direct intra-articular antibiotic infusion, which can provide a high concentration of intra-articular antibiotic, has been used in combination with DAIR to improve treatment outcomes among patients in our institution. This study aimed to assess the outcomes of DAIR combined with direct intra-articular antibiotic infusion in patients who presented with acute hematogenous PJI after TKA. Methods We reviewed the data of all patients diagnosed with acute hematogenous PJI after primary TKA (from 2008 to 2015) who received DAIR combined with direct intra-articular antibiotic infusion. Results In total, 15 knees in 12 patients were semi-urgently treated with this method. The mean follow-up time was 93.3 (minimum: 56) months, and the longest follow-up time was 11 years. Two patients (n = 3 knees) had a well-functioning, non-infected prosthesis 6 and 10 years after the procedure. Two patients (n = 2 knees) had re-infection 2 and 5 years after surgery, and they required two-stage revision. None of the patients were lost to follow-up. Finally, 13 (86.6%) of 15 infected knees were successfully treated with this method. Conclusions DAIR combined with direct intra-articular antibiotic infusion is an effective treatment for acute hematogenous PJI after TKA.
Soft tissue release and gap balancing in total knee arthroplasty (TKA) are important issue and lack of conclusive result. We performed posteromedial capsule (PMC) and superficial medial collateral ligament (sMCL) release by preservation of anterior attachment of pes anserine. Gaps and alignment were recorded by computer assisted surgery measurement. Results: T: The mean correction of varus deformity after PMC release and sMCL release were 4.88 ± 2.82° and 3.39 ± 1.7 respectively with the mean FC after PMC and sMCL release correction of 5.57 ± 3.5 and 1.34 ± 2.9° respectively. The mean medial gap changes on full extension after PMC and sMCL release was 1.83 ± 1.39 and 1.67 ± 1.04 mm. respectively with the mean medial gaps at 90 degree flexion after PMC and sMCL release changes of 0.73 ± 0.9 and 5.14 ± 2.11 mm. respectively. The mean lateral gap changes on extension after PMC and sMCL release were -1.3 ± 1.83 and -1.1 ± 1.6 mm. respectively with the mean lateral gaps at 90 degree flexion after PMC and sMCL release changes of -0.19 ± 1.03 and 0.06 ± 1.75 mm. here were 21 patients (16 female and 5 male) with mean age of 68 (48-78) years. The mean body mass index was 28.49 (20.70 – 39.95) kg/m2. The mean preoperative hip-knee-ankle angle was varus 8.12 (3.5-16.0) degrees with mean flexion contracture of 11.3 (3.5-16.0) degrees. Sixteen knees were implanted with Fixed bearing knee prosthesis and five knees were implanted with Mobile bearing knee prosthesis (Table.1). We performed PMC release in all patients, and combined PMC and sMCL release in fourteen patients. The mean correction of varus deformity after PM release and sMCL release were 4.88 ± 2.82 and 3.39 ± 1.7 degrees respectively. While the mean correction of flexion contracture after PMC release and sMCL release were 5.57 ± 3.5 and 1.34 ± 2.9 degrees respectively (Fig.8). The mean medial gaps change on extension after PMC and sMCL release were 1.83 ± 1.39 and 1.67 ± 1.04 mm. respectively. The mean medial gaps change at 90 degree flexion after PMC and sMCL release were 0.73 ± 0.9 and 5.14 ± 2.11 mm. respectively (Fig.9). The mean lateral gaps change on extension after PMC and sMCL release were 1.3 ± 1.83 and -1.1 ± 1.6 mm. respectively. The mean lateral gaps change at 90 degree flexion after PMC and sMCL release were -0.19 ± 1.03 and 0.06 ± 1.75 mm. (Fig.9). There is no instability of knee after PMC and sMCL release. Materials and Methods: Twenty one patient had been operated on. TKA with computer assisted surgery was performed using PMC and sMCL release by preservation of anterior attachment of pes anserine. Alignment, medial and lateral gaps were measured by computer assisted surgery. The mean age was 68 (48-78) years with the mean preoperative hip-kneeankle angle of 8.12 (3.5-16.0) degrees and the mean flexion contracture (FC) of 11.3 (3.516.0) degrees. Conclusion: We believe that sMCL release with preservation of anterior attachment of pes anserinus in total knee arthroplasty has additional effect on varus knee correction after PMC release without creation of knee instability.
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