Faculty Bibliography

BACKGROUND:Perioperative pain management for patients undergoing total knee arthroplasty (TKA) improves patient outcomes and facilitates recovery. In this study, we compared the effects of preoperative oral acetaminophen vs intravenous (IV) acetaminophen administered once intraoperatively and once postoperatively. METHODS:Two standardized, multimodal analgesia protocols were compared in patients undergoing primary, unilateral TKA. The oral acetaminophen cohort (OA) received doses of oral acetaminophen preoperatively and an as-needed basis postoperatively (n = 698). The IV acetaminophen cohort (IA) received 2 doses of IV acetaminophen, one intraoperative and one 6 hours postoperatively, with no oral acetaminophen given (n = 318). No other variables were significantly changed during the study period. RESULTS:The IV acetaminophen group demonstrated less narcotic usage on postoperative day 0 (OA: 13.3 mme [morphine mg equivalents], IA: 6.2 mme, P < .001) and overall usage (OA: 66.1 mme, IA: 48.5 mme, P < .001). Pain scores were statistically and clinically significantly decreased in the immediate postoperative (the first 8 hours) for the IA group (OA: patient-reported pain scores of 4.0; IA: patient-reported pain scores of 2.0, P < .001). Both groups progressed and completed their physical therapy similarly for each postoperative day. Length of stay and percent discharge home were slightly improved in the IA group as well, however did not reach statistical difference. CONCLUSION/CONCLUSIONS:An iterative approach to multimodal pain management after TKA led to improvements in narcotic usage, pain scores, and several quality measures. IV acetaminophen is an integral and effective part of our opioid-sparing multimodal pain regimen in TKA.

Successful management of human immunodeficiency virus (HIV) has lengthened the life expectancy of HIV-positive (HIV + ) patients; consequently, increasing numbers of this patient population are candidates for total knee arthroplasty (TKA). This study seeks to provide detailed results of TKA in HIV+ patients and compare them to an HIV-negative (HIV - ) cohort. We performed a multicenter retrospective case-control study comparing 25 HIV+ patients to 25 HIV- patients undergoing TKA. The analysis included a cohort and subgroup stratification based on the presence or absence of postoperative complications. Prior to TKA, all 25 patients had a documented history of HIV infection. No intraoperative complications were reported. Ninety-day postoperative complications included knee contracture (one HIV + , no HIV - , p = 0.3124), periprosthetic joint infection requiring revision (one HIV + , no HIV - , p = 0.3124), mechanical fall requiring incision and drainage (one HIV + , no HIV - , p = 0.3124), and death (one HIV + , no HIV - , p = 0.3124). The average follow-up was 18.80 months. HIV+ patients stayed in the hospital for an average of 3.8 days following surgery, which was significantly greater than HIV- patients (2.28 days; p = 0.0040). As the life expectancy for HIV+ patients improves, a greater number will be TKA candidates. This study has shown an acceptable postoperative complication risk in an HIV+ patient population undergoing TKA, albeit with a significantly increased hospital length of stay.

Unsafe opioid distribution remains a major concern among the total knee arthroplasty (TKA) population. Perioperative opioid use has been shown to be associated with poorer outcomes in patients undergoing TKA including longer length of stay (LOS) and discharges to extended care facilities. The current study aims to detail perioperative opioid use patterns and investigate the effects of preoperative chronic opioid use on perioperative quality outcomes in TKA patients. A retrospective analysis was performed on 338 consecutive TKAs conducted at our institution. Two cohorts were compared in this study-preoperative chronic opioid users and nonchronic opioid users. Opioid usage patterns and quality metrics were collected and analyzed over a 3-month preoperative and a 6-month postoperative period. Fifty-four (16.0%) preoperative chronic opioid users were identified out of the total 338 patients included in the study. Preoperative chronic opioid users experienced significantly longer LOS (2.9 vs 2.6 days; p = 0.026). Patients who remained persistent chronic users throughout the preoperative and postoperative stages demonstrated a significantly longer LOS (3.4 days vs 2.5 days; p = 0.017) compared with those who were no longer chronically using opioids by the 6 months postoperative period. By the 6 months postoperative time point, preoperative chronic users were consuming eight times the morphine-equivalents (mg/day) compared with nonchronic users (p < 0.001). Preoperative chronic opioid use was associated with substantially higher usage patterns throughout the postoperative stages. Such opioid use patterns were associated with longer LOS. Given that perioperative chronic opioid use has shown to negatively impact TKA outcomes, future studies refining current perioperative management strategies are warranted. This is a Level II, Prognostic Study.

AIMS:Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA. The purpose of this multicentre randomized clinical trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA. PATIENTS AND METHODS:-tests for equivalence. RESULTS:In total, one patient withdrew, five did not undergo surgery, 16 were screening failures, and 25 did not receive the assigned treatment, leaving 186 patients for analysis. There was no significant difference in haemoglobin reduction among treatments (2.8 g/dl for single-dose IV TXA, 2.6 g/dl for double-dose IV TXA, 2.6 g/dl for combined IV/topical TXA, 2.9 g/dl for oral TXA; p = 0.38). Similarly, calculated blood loss (p = 0.65) and transfusion rates (p = 0.95) were not significantly different between groups. Equivalence testing assuming a 1 g/dl difference in haemoglobin change as clinically relevant showed that all possible pairings were statistically equivalent. CONCLUSION:2019;101-B(Supple 7):10-16.