Knee arthroplasty: hospital length of stay and co-morbidity

Introduction Total knee replacement (TKR) is one of the most common orthopaedic procedures performed in Italy with an increase practice of 11 % from 2001 to 2009. The current need is therefore to reduce hospital length of stay in order to meet the increased demand and lower the costs of hospitalization. Materials and methods Post-operative outcomes of patients who underwent TKR at the 1st Orthopaedic Division of Pisa University between April 2008 and September 2009 were evaluated retrospectively. The sample consisted of 100 patients with a mean age of 70 years. All patients diagnosed with knee osteoarthritis undertaking a primary TKR were included in the study. Referring to fast-track protocols we have considered: age, sex, BMI, co-morbidities and ASA score, number of blood units transfused, post-operative analgesia protocol, physiotherapy protocol, day of the week when surgical procedure was performed, surgical access route. Each parameter was correlated with length of stay in order to identify whether, and how it would influence the post-operative period. The physiotherapy protocol for all patients began the first post-operative day. Post-operative analgesia was based on the use of ketorolac and morphine in elastomeric pump for 48 h, with paracetamol as rescue treatment. The surgical route was Midvastus in all patients and all surgical procedures were performed by the same operator. Results In our series (2008–2009), the average length of hospital stay was 9.25 days. Among analyzed factors, the following resulted to be predictive of length of stay (p\0.05): ASA score C3 (+1.5 days), BMI C 30 (+2.3 days), need for blood transfusion C2 (+3.26 days), age C75 (+2.12 days). Discussion Bleeding was shown to be the most important amendable variable that if controlled could lead to a significant reduction in length of stay. Obesity and consequently reduced mobilization could be addressed with a more aggressive and early rehabilitation protocol. ASA and age which had a significant impact with length of stay are not modifiable. Conclusions The identification of the variables influencing length of stay is important to reduce costs and deliver a better care for patients. In view of the results of this audit, we have monitored more closely bleeding by introducing the use of the tranexamic acid and promotingearly mobilization in obese patients, in agreement with the most recent literature. The preliminary results obtained, following this new approach, appear to be satisfactory (TKR mean hospital length of stay reduced of 2 days)

Teriparatide and clodronate combination as a potential treatment for complex regional pain syndrome type I in delayed consolidation after foot surgery: a case report and review of the literature

Abstract Background Complex regional pain syndrome type I is a pathological condition characterized by an exaggerated response of tissues to low or moderate pain stimuli. The exact pathogenesis and optimal medical treatment for complex regional pain syndrome type I are still not fully understood, although bisphosphonates have shown positive effects in reducing pain. Foot surgery can be complicated by the development of complex regional pain syndrome type I, leading to functional decline and difficulties in weight-bearing. Case presentation The authors present a clinical case involving complex regional pain syndrome type I that developed after surgical foot arthrodesis. The patient, a 42-year-old Caucasian male, did not respond to clodronate treatment but experienced successful outcomes upon the addition of teriparatide, which effectively stimulated the healing of arthrodesis. Conclusion Teriparatide cannot be considered the primary treatment for complex regional pain syndrome due to insufficient solid clinical data. However, when complex regional pain syndrome is associated with or caused by delayed union, teriparatide can be used to address the underlying cause of complex regional pain syndrome

Clinical and radiographic short mid-term outcomes of primary total stabilizer knee arthroplasty

A successful Total Knee Arthroplasty (TKA) requires stability, but rarely in primary TKA, a prosthesis with more constraint than a posterior-stabilizer (PS) is necessary. In patients with severe varus/valgus deformities with incompetent collateral ligaments or in knees that cannot be adequately balanced after ligaments release, a total-stabilizer (TS) prosthesis may be required. The purpose of our retrospective study is to evaluate clinical and radiographic outcomes at short mid-term follow-up in patients treated with a TS TKA. Between January 2013 and August 2016, 36 patients (38 knees) were treated with Stryker Triathlon TS cemented implants. Clinical and radiographic evaluation were performed preoperatively and postoperatively at 1 month, 3 months, 6 months, 1 year and at 1-year intervals thereafter. At final follow-up, 33 patients (35 knees) remained and were included in this study and followed with a mean follow-up of 26.6 months. Clinical evaluation was performed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC score) and the Knee Society rating system that is subdivided into a knee score (KS) that rates only the knee joint itself and a functional score (FS). Knee Score (KS) and Functional Score (FS) increased significantly from a mean pre-operative value of 48 and 45, respectively, to a post-operative value at last follow-up of 86 and 82, respectively. Also WOMAC score improved significantly: the mean pre-operative WOMAC score was 45, while the mean post-operative WOMAC score, at last follow-up, was 19. The difference between pre- and post- operative results was significant at statistical analysis. In our opinion, when the adequately prosthesis balancing isn’t possible, because of primary or secondary severe varus/valgus deformity or severe soft tissues retraction, an available option is to perform a total knee arthroplasty with a total stabilizer polyethylene insert. TS prosthesis gives more stability during the most of ROM and, in addition, Triathlon system provides surgeons the possibility to choose a more constrained implant, than a standard PS one, during surgical procedure saving the bone stock. Our experience with this kind of prosthesis has provided good clinical and radiographic outcomes at a short mid-term follow-up with a low-rate of complications

Is the Combination of Platelet-Rich Plasma and Hyaluronic Acid the Best Injective Treatment for Grade II-III Knee Osteoarthritis? A Prospective Study

Background. Knee osteoarthritis is a common disease with increasing incidence and prevalence in western countries. It can cause severe pain and functional limitations, thereby representing a threat for patients' quality of life and a burden for national health systems. Intra-articular injections with hyaluronic acid (HA) and platelet-rich plasma (PRP) have been used for decades in order to reduce the symptoms caused by osteoarthritis. In recent years, a combination of HA and PRP has been introduced in clinical practice with the aim to minimize the clinical presentation of osteoarthritis and potentially delay articular degeneration. Materials and Methods. Sixty cases with grade II-III knee osteoarthritis according to the Kellgren-Lawrence classification were included in a prospective study, focused on the evaluation of clinical and functional outcomes after intra-articular knee injections. Cases were randomly divided into three groups. Twenty cases (Group A) were injected with HA, 20 (Group B) had PRP, and the remaining 20 (Group C) received a combination of HA and PRP. Basal WOMAC score and VAS score were recorded before the treatment and repeated within 3 and 6 months after the treatment. Results. At 6-month follow-up, Group C (PRP + HA) was the one with the lowest WOMAC and VAS mean values. It was also the only group that reported a reduction in the two values both in the first three months and in the following three months. No major complication was recorded. Conclusion. The combination of platelet-rich plasma and hyaluronic acid can be effective in the treatment of grade II-III knee osteoarthritis in a short-to-mid-term scenario. It represents an innovative and valuable alternative to the administration of its two components alone

Instability severity index score does not predict the risk of shoulder dislocation after a first episode treated conservatively

The first purpose of this study was to verify the association between Instability Severity Index Score (ISIS) and Recurrent Shoulder Dislocation (RSD) after a first episode treated conservatively. The second aim is to identify the risk factors associated with RSD after a primary acute shoulder anterior dislocation treated conservatively. A total of 111 patients with first traumatic anterior shoulder dislocation treated at a single trauma centre between January 2014 and March 2016 were enrolled. The main predictive variables of risk factors and the ISIS score were calculated. Among the 85 patients included, 26 cases of RSD were observed (30.6%). Considering the whole population, no significant association between ISIS and RSD were reported. Regarding other risk factors, high-risk working activities and rotator cuff injury had a significantly higher RSD risk. Sex, dominant limb, familiar history, hyperlaxity, contact or overhead sports, competitive sport, post-reduction physiokinesitherapy, return to sports activity time, Hill-Sachs lesion, bony Bankart lesion and great tuberosity fracture did not seem to influence the risk of RSD. No correlation between ISIS score and RSD in patients treated conservatively after a first episode of shoulder dislocation were reported. The only risk factors with a significant association to RSD were high-risk working activities and rotator cuff injury