High Cure Rate for Acute Streptococcal Prosthetic Joint Infections Treated With Debridement, Antimicrobials, and Implant Retention in a Specialized Tertiary Care Center

Streptococcal prosthetic joint infections (PJIs) treated with debridement, exchange of removable parts, antibiotics, and implant retention within 3 weeks from symptom onset had an implant survival rate of 97.9% and an implant survival rate without suppressive antimicrobials of 80.9%. Treatment centralization for acute streptococcal PJIs to specialized centers makes excellent cure rates possible.Non peer reviewe

Verityhjiön käyttö polven tekonivelkirurgiassa - Tourniquet use in total knee arthroplasty

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Postoperative pain as a risk factor for stiff knee following total knee arthroplasty and excellent patient-reported outcomes after manipulation under anesthesia

Background and purpose - Manipulation under anesthesia (MUA) is the first-choice treatment for stiffness following total knee arthroplasty (TKA) unresponsive to pain management and physiotherapy. Some of the predisposing factors and patient-reported outcome measures (PROMs) following MUA remain poorly studied. We retrospectively investigated the etiological risk factors and the outcomes of MUA. Patients and methods - 391 TKA patients from a randomized trial comparing the use of a tourniquet and anesthesia (spinal or general) were analyzed, and patients needing MUA were identified (MUA group). We evaluated in-hospital opioid consumption, Oxford Knee Score (OKS), range of motion (ROM), and pain assessed by the Brief Pain Inventory-short form with a 1-year follow-up. Results - 39 (10%) MUA patients were identified. The MUA patients were younger (60 years vs. 64 years, difference -4, 95% CI -6 to -1) and had higher postoperative oxycodone consumption (66 mg vs. 51 mg, median difference 11, CI 1-22) than the no-MUA patients. The proportion of MUA patients who contacted the emergency department within 3 months because of pain was larger than that of non-MUA patients (41% vs. 12%, OR 5, CI 3-10). At the 1-year follow-up, the ROM was improved by 39 degrees following MUA, but the total ROM was worse in the MUA group (115 degrees vs. 124 degrees, p < 0.001). No difference was found in the OKS between the MUA and no-MUA patients. Interpretation - Higher postoperative pain seems to predict MUA risk. MUA performed 3 months postoperatively offers substantial ROM improvement and comparable PROMs to no-MUA patients 1 year after TKA.Peer reviewe

Hammaslääkärin tarkastuksen tarpeellisuus tekonivelleikkaukseen tulevilla potilailla : prospektiivinen kyselytutkimus

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Effects or anaesthesia method and tourniquet use on recovery following total knee arthroplasty : a randomised controlled study

Background: We investigated the effects of spinal and general anaesthesia and surgical tourniquet on acute pain and early recovery after total knee arthroplasty (TKA). Methods: Patients (n=413) were randomised to four parallel groups: spinal anaesthesia with or without tourniquet, and general anaesthesia with or without tourniquet. The primary outcome was patient-controlled i.v. oxycodone consumption over 24 postoperative hours. Results: Results from 395 subjects were analysed. Median i.v. oxycodone consumption did not differ between the four groups (spinal anaesthesia without [36.6 mg] and with tourniquet [38.0 mg], general anaesthesia without [42.3 mg] and with tourniquet [42.5 mg], P=0.42), between spinal (37.7 mg) and general anaesthesia (42.5 mg) groups (median difference -3.1, 95% confidence interval [CI] -7.4 to 1.2, P=0.15) and between tourniquet and no-tourniquet groups (40.0 vs 40.0 mg, median difference -0.8, CI -5.1 to 3.5, P=0.72). Vomiting incidence was higher with spinal than with general anaesthesia (21% [42/200] vs 13% [25/194], CI 1.05 to 3.1, P=0.034). The mean haemoglobin decrease was greater without than with tourniquet (-3.0 vs -2.5 g dl(-1), mean difference -0.48, CI -0.65 to -0.32, P Conclusions: For TKA, spinal and general anaesthesia with or without tourniquet did not differ in 24-h postoperative opioid consumption, pain management, blood transfusions, in-hospital complications, and length of hospital stay. Vomiting incidence was higher in the spinal than in the general anaesthesia group. Tourniquet use caused smaller decreases in haemoglobin levels.Peer reviewe

Verityhjiön käytön vaikutus polven tekonivelleikkauksen tuloksiin: satunnaistettu tutkimus

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OPTIMIZING THE OUTCOMES IN TOTAL KNEE ARTHROPLASTY WITH PERIOPERATIVE TREATMENT PROTOCOLS

Aims Elective total knee arthroplasty (TKA) is one of the most common in-hospital surgeries for patients with knee osteoarthritis (OA) when conservative treatment has failed. In Finland, approximately 13,000 TKAs were performed in 2020. Given the projections that the incidence of TKA will increase, this causes a significant burden to health care, even though TKA is a cost-effective procedure. Despite enhancements in surgery and postoperative care, up to 20 percent of patients are dissatisfied following TKA. High-level evidence regarding the effects of a widely used surgical tourniquet, and spinal anesthesia (SA) or general anesthesia (GA) on patient recovery, patient-reported outcomes, and patient satisfaction with TKA remains scarce. This trial aimed to determine the optimal combination of tourniquet and anesthesia methods used during TKA regarding immediate recovery, patient-reported and functional outcomes, adverse events, and patient satisfaction with TKA in a 12-month follow-up. Methods We conducted a randomized trial comprising 404 patients aged 18–75 years with Kellgren-Lawrence Grade 3 or 4 OA, body mass index (BMI) ≤ 40, American Society of Anesthesiologists (ASA) Class I–III, and eligible for elective fast-track TKA. The trial was conducted in a single tertiary care arthroplasty center in Helsinki University Hospital between October 2016 and December 2019. We evaluated the effect of tourniquet (T) or no tourniquet (NT) use, and the effects of SA and GA on postoperative oxycodone consumption with patient-controlled analgesia (PCA) in the first 24 hours, surgical and tourniquet times, blood loss, postoperative pain and nausea, length of stay (LOS), adverse events, knee range of motion (ROM), patient-reported outcome measures assessed using the Oxford Knee Score (OKS), health-related quality of life (HRQoL) using the 15D tool (15D), prolonged pain using the Brief Pain Inventory short form (BPIsf), and patient satisfaction with TKA. Study I describes the previous literature and rationale for our study, as well as a rigorous and detailed research protocol and statistical analysis plan. Study II describes the in-hospital results of the studied regimens regarding postoperative oxycodone consumption with PCA in the first 24 hours as a primary outcome and postoperative pain and nausea, surgical blood loss, in-hospital complications, and LOS as secondary outcomes. Study III, comprising 391 patients, discusses the 3- and 12-month functional outcomes of the operated-on knees assessed with OKS as a primary outcome. Secondary outcome measures included operative and tourniquet times, adverse events, ROM, the proportion of patients reaching OKS minimal important change (MIC) and OKS patient acceptable symptom state (PASS), satisfaction with TKA and anesthesia methods, and HRQoL assessed with 15D. Study IV, a comparative retrospective analysis, describes the etiological factors and patient-reported outcomes on patients with a postoperative stiff knee who underwent manipulation under anesthesia (MUA) three months after TKA. The patients of Study IV comprised the prospective patient cohort of the original Studies II and III. Main results In Study II, comprising 395 patients, we found no significant differences between the groups regarding the cumulative oxycodone consumption in the first 24 hours postoperative. Additionally, pain at 24 hours postoperatively, blood transfusion rates, in-hospital complications, or LOS between the two-group (NT vs. T and SA vs. GA) or the four-group (NT/SA, T/SA, NT/GA, and T/GA) comparisons did not differ. Tourniquet use decreased blood loss, but it did not have a significant effect on blood transfusion rates. Postoperative nausea and vomiting (PONV) incidence was higher in the SA group than in the GA group but without affecting general recovery. In Study III, comprising 391 patients, in the two-group comparisons, the NT group reached OKS PASS more seldom than the T group (77.0% vs. 84.8%, odds ratio [OR] 0.59, 95% confidence intervals [CI] 0.35–0.997, p = 0.049). Surgical time, adverse events, total OKS, and 15D score at 12 months postoperatively did not differ regardless of tourniquet use. The SA group reported more substantial improvement in OKS (16.21 vs. 14.1, mean difference 2.13, 95% CI 0.55–3.71, p = 0.008) and 15D score (0.051 vs. 0.033, mean difference 0.016, 95% CI 0.003–0.030, p = 0.019). In addition, the SA group had a higher proportion of patients reaching OKS MIC (91.7% vs. 81.7%, OR 2.49, 95% CI 1.32–4.69, p = 0.005) and OKS PASS (86.0% vs. 75.7%, OR 2.00, 95% CI 1.18–3.39, p = 0.010), than the GA group. Satisfaction with the anesthesia method used during TKA was very high in both groups without significant difference. Surgical time, adverse events, and 15D score at 12 months postoperatively did not differ significantly. In the four-group comparisons, patients in the T/SA had the most substantial improvements in OKS (16.82) and the highest proportion of patients reaching OKS MIC (95.7%) and OKS PASS (92.6%). Regarding 90-day adverse events and 15D score at 12 months postoperatively, we found no significant differences between the four groups. In Study IV, we found a 10% incidence of MUA (39/391). A younger age, higher preoperative pain severity scores assessed using BPIsf, and higher postoperative in-hospital opioid consumption seemed to be prognostic factors for MUA. Patients with stiff knees gained significant ROM benefit from MUA performed at three months postoperative (mean gain of 39 degrees). The final OKS at 12 months after TKA in MUA patients was comparable to patients without postoperative stiff knees (42.0 vs. 43.0, p = 0.15). No MUA-related complications appeared. The final ROM at the 12-month follow-up in the MUA group was approximately ten degrees less (115 vs. 124, p = < 0.001) than in the no-MUA group. Conclusions We found the use of a surgical tourniquet and both anesthesia regimens safe in TKA without clinically significant differences in terms of surgical time, postoperative pain, the number of blood transfusions, LOS, adverse events, total OKS, and quality of life assessed using 15D at 12 months postoperatively. According to these results, a surgical tourniquet has no detrimental effect on the outcomes of TKA. The patients undergoing TKA benefit from SA in terms of improvements in OKS and 15D score. At the 12-month follow-up, T/SA resulted in the most substantial improvements in OKS and had the highest proportion of patients reaching OKS MIC and OKS PASS. Patients with postoperative stiff knee benefit from MUA performed three months postoperatively. In a 12-month follow-up, the patients who received MUA resulted in nearly comparable functional outcomes to patients who did not have postoperative stiff knee.Polven tekonivelleikkaus on vakiintunut hoito edenneen polven nivelrikon hoidossa. Polven tekonivelleikkauksia tehdään lisääntyvästi ja määrän odotetaan edelleen kasvavan väestön ikääntyessä ja ylipainon lisääntyessä. Polven tekonivelleikkauksen hyvistä tuloksista huolimatta useissa tutkimuksissa on havaittu, että jopa noin 20 % potilaista jää tyytymättömiksi polven toiminnalliseen lopputulokseen. Pitkittynyt leikkauksenjälkeinen kipu on tunnistettu yhdeksi yleisimmistä tyytymättömyyden syistä aiheuttaen merkittävää haittaa potilaille. Aiempien tutkimusten perusteella polven tekonivelleikkauksen yhteydessä käytettävän kirurgisen verityhjiön on uskottu nopeuttavan leikkausta ja vähentävän verenvuotoa. Joissakin tutkimuksissa on kuitenkin havaittu, että verityhjiön käyttö lisää leikkauksen jälkeistä kipua ja komplikaatioita. Rekisteritutkimusten perusteella polven tekonivelleikkauksen ensisijaiseksi anestesiamenetelmäksi on suositeltu spinaali- eli selkäydinpuudutusta, koska komplikaatioita on todettu olevan hieman vähemmän kuin yleisanestesiassa. Tutkimusnäyttö spinaalipuudutuksen hyödyistä on ollut kuitenkin laadultaan heikkoa. Näiden yleisesti käytettyjen anestesiamenetelmien vaikutus leikkauksen jälkeiseen kipuun ja polven toiminnalliseen tulokseen on ollut selvittämättä. Tämän väitöskirjan tavoitteena on ollut selvittää polven tekonivelleikkauksessa käytettävän verityhjiön sekä spinaalipuudutuksen ja yleisanestesian vaikutuksia leikkauksen tuloksiin. Tutkimus oli 404 potilaan neljän ryhmän satunnaistettu rinnakkaistutkimus yhden vuoden seuranta-ajalla. Tutkimus toteutettiin Helsingin Yliopistollisen sairaalan Peijaksen sairaalassa vuosina 2016–2019. Tutkimuksemme päämuuttujina olivat leikkauksen jälkeinen oksikodoni-lääkkeen kulutus ensimmäisten 24 tunnin aikana sekä polven toiminnallinen tulos yhden vuoden jälkeen leikkauksesta. Selvitimme myös tutkittujen menetelmien vaikutusta leikkauksen jälkeiseen toipumiseen ja potilastyytyväisyyteen. Tutkimuksemme osoitti, että verityhjiön käyttö sekä molemmat anestesiamenetelmät ovat turvallisia ilman merkittävää vaikutusta leikkauksen jälkeiseen kipuun, toipumiseen, tai keskimääräiseen polven tekonivelen toiminnalliseen lopputulokseen. Potilaat, joille käytettiin leikkauksessa verityhjiötä selkäydinpuudutuksen kanssa, saavuttivat useimmiten toiminnallisesti erinomaisen, ryhmien vertailussa parhaimman, lopputuloksen (93 %), ja he olivat tyytyväisimpiä leikkauksen lopputulokseen (94 %). Tutkimuksen perusteella polven toiminnallista lopputulosta ja potilastyytyväisyyttä voidaan parantaa valitsemalla spinaalipuudutus ja verityhjiö polven tekonivelleikkauksen ajaksi.Julkaistu painettuna: Helsinki: Unigrafia, 202

Effect of a multidisciplinary team on the treatment of hip and knee prosthetic joint infections : a single-centre study of 154 infections

Background A multidisciplinary team responsible for the management plan of prosthetic joint infections (PJI) was founded in January 2008. The aim of this study was to investigate whether a decrease in the number of surgeries and length of stay (LOS) was seen in the management of PJI with the aid of the multidisciplinary team. Methods This retrospective cohort study consisted of a total of 154 postoperative PJIs from three time periods: 21 PJIs from 2005 to 2007 (Group 1), 65 PJIs from 2011 to 2013 (Group 2), and 68 PJIs from 2015 to 2016 (Group 3). Successful outcome was classified as the retention of the original implant or revised implant and no infection-related death. Results The median number of operations decreased from 2.0 operations (Group 1) to 1.0 operation (Group 3) (p = .023), and the median LOS was shortened from 49.0 days (Group 1) to 17.0 days (Group 3) (p = .000). The number of PJIs treated with two-stage exchange decreased from 52.4% (11/21, Group 1) to 16.2% (11/68, Group 3) (p = .004). Simultaneously, debridement, antibiotics, and implant retention (DAIR) as primary surgical treatment increased from 42.9% (9/21, Group 1) to 89.7% (61/68, Group 3) (p = .000). The successful outcome of DAIR improved from 55.6% (5/9, Group 1) to 85.2% (52/61, Group 3) (p = .077). Conclusions Treatment of PJI in a specialized centre with the aid of a multidisciplinary team lead to fewer surgeries and reduced LOS. Successful outcome of DAIR improved over time.Peer reviewe

Intravenous patient-controlled analgesia vs nurse administered oral oxycodone after total knee arthroplasty : a retrospective cohort study

Objectives: Severe post-operative pain is common after total knee arthroplasty. Patient-controlled analgesia is an alternative method of pain management, whereby a patient administers his or her own pain medication. Patients seem to prefer this method over nurse-administered analgesia. However, it remains unclear whether patients using patient-controlled analgesia devices use higher or lower doses of opioids compared to patients treated with oral opioids. Methods: This retrospective study examined 164 patients undergoing total knee arthroplasty. Post-operatively, 82 patients received oxycodone via intravenous patient-controlled analgesia devices, while the pain medication for 82 patients in the control group was administered by nurses. The main outcome measure was the consumption of intravenous opioid equivalents within 24 h after surgery. Secondary outcome measures were the use of anti-emetic drugs and the length of stay. Furthermore, we evaluated opioid-related adverse event reports. Results: The consumption of opioids during the first 24 h after surgery and the use of anti-emetic drugs were similar in both groups. The median opioid dose of intravenous morphine equivalents was 41.1 mg (interquartile range (IQR): 29.5-69.1 mg) in the patient-controlled analgesia group and 40.5 mg (IQR: 32.4-48.6 mg) in the control group, respectively. The median length of stay was 2 days (IQR: 2-3 days) in the patient-controlled analgesia group and 3 days (IQR: 2-3 days) in the control group (p=0.02). The use of anti-emetic drugs was similar in both groups. Conclusions: The administration of oxycodone via intravenous patient-controlled analgesia devices does not lead to increased opioid or anti-emetic consumptions compared to nurse-administered pain medication after total knee arthroplasty. Patient-controlled analgesia might lead to shortened length of stay.Peer reviewe

Testing of a predictive risk index for persistent postsurgical pain on patients undergoing total knee arthroplasty : A prospective cohort study

BackgroundWe investigated whether a universal predictive risk index for persistent postsurgical pain (PPP) is applicable to patients who undergo total knee arthroplasty (TKA). MethodsIn this cohort study, 392 participants of a randomized study investigating the effects of anaesthesia methods and tourniquet use on TKA were divided into low-, moderate-, and high-risk groups for PPP, as suggested in the previous risk index study. Patients reported pain using the Oxford Knee Score pain subscale and Brief Pain Inventory-short form preoperatively and 3 and 12 months postoperatively. We compared the pain scores of the low- to moderate- and high-risk groups at respective time points and investigated changes in pain scores and the prevalence of PPP at 3 and 12 months after surgery. ResultsThe high-risk group reported more pain 3 and 12 months after TKA than the low- to moderate-risk group. However, of seven variables, only a single difference reached the threshold for minimal clinical importance between the groups at 12 months. Additionally, at 12 months, the low- to moderate-risk group reported slightly worse improvements in three of seven pain variables than the high-risk group. Depending on the definition, the prevalence of PPP ranged from 2% to 29% in the low- to moderate-risk group and 4% to 41% in the high-risk group 12 months postoperatively. ConclusionsAlthough the investigated risk index might predict clinically important differences in PPP between the risk groups at 3 months after TKA, it seems poorly applicable for predicting PPP at 12 months after TKA. SignificanceAlthough many risk factors for persistent postsurgical pain after total knee arthroplasty have been identified, predicting the risk of this pain has remained a challenge. Results of the current study suggest that accumulation of previously presented modifiable risk factors might be associated with increased postsurgical pain at 3 months, but not at 12 months after total knee arthroplasty.Peer reviewe