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Background and ObjectivesThe role of a fascia iliaca compartment block (FICB) for postoperative analgesia after total hip arthroplasty (THA) remains questionable. High-dose local anesthetics and a proximal injection site may be essential for successful analgesia. High-dose local anesthetics may pose a risk for local anesthetic systemic toxicity. We hypothesized that a high-dose longitudinal supra-inguinal FICB is safe and decreases postoperative morphine consumption after anterior approach THA.MethodsWe conducted a prospective, double blind, randomized controlled trial. Patients scheduled for THA were randomized to group FICB (longitudinal supra-inguinal FICB with 40-mL ropivacaine 0.5%) or group C (control, no block). Standard hypothesis tests (t test or Mann-Whitney U test, χ2 test) were performed to analyze baseline characteristics and outcome parameters. The primary end point of the study was total morphine (mg) consumption at 24 hours postoperatively. Serial total and free ropivacaine serum levels were determined in 10 patients.ResultsAfter obtaining ethical committee approval and written informed consent, 88 patients were included. Mean (SD) morphine consumption at 24 hours postoperatively was reduced in group FICB compared to group C: 10.25 (1.64) mg versus 19.0 (2.4) mg (P = 0.004). Using a mean dose of 2.6-mg/kg ropivacaine (range, 2–3.4 mg/kg), none of the patients had total or free ropivacaine levels above the maximum tolerated serum concentration.ConclusionsWe conclude that a high-dose longitudinal supra-inguinal FICB reduces postoperative morphine requirements after anterior approach THA.Clinical Trials Registry: EU Clinical Trials Register. www.clinicaltrialsregister.eu #2014-002122-12.

Background The presented prospective randomized controlled single-centre study compares the clinical outcome up to 12 months after total hip arthroplasty using a minimally invasive single-incision direct anterior (DAA) and a direct transgluteal lateral approach. Methods A total of 123 arthroplasties were evaluated utilizing the Harris Hip Score (HHS), the extra short musculoskeletal functional assessment questionnaire (XSFMA), the Short Form 36 (SF-36) health survey, a Stepwatch™ Activity Monitor (SAM), and a timed 25 m foot walk (T25-FW). Postoperative x-ray images after THA were reviewed to determine inclination and stem positioning. Results At final follow-up, the XSFMA functional index scores were 10.3 (anterior) and 15.08 (lateral) while the bother index summed up to a score of 15.8 (anterior) and 21.66 (lateral) respectively, thus only differing significantly for the functional index ( p  = 0.040 and p  = 0.056). The SF-36 physical component score (PCS) was 47.49 (anterior) and 42.91 (lateral) while the mental component score (MCS) summed up to 55.0 (anterior) and 56.23 (lateral) with a significant difference evident for the PCS ( p  = 0.017; p  = 0.714). Patients undergoing THA through a DAA undertook a mean of 6402 cycles per day while those who had undergone THA through a transgluteal approach undertook a mean of 5340 cycles per day ( p  = 0.012). Furthermore, the obtained outcome for the T25-FW with 18.4 s (anterior) and 19.75 s (lateral) and the maximum walking distance (5932 m and 5125 m) differed significantly ( p  = 0.046 and p  = 0.045). The average HHS showed no significant difference equaling 92.4 points in the anterior group and 91.43 in the lateral group ( p  = 0.477). The radiographic analysis revealed an average cup inclination of 38.6° (anterior) and 40.28° (lateral) without signs of migration. Conclusion In summary, our outcomes show that after 1 year THA through the direct anterior approach results in a higher patient activity compared to THA utilizing a transgluteal lateral approach while no differences regarding hip function are evident. Trial registration DRKS00014808 (German Clinical Trial Register DRKS); date of registration: 31.05.2018.

Background There are indications of beneficial short-term effect of pre-operative exercise in reducing pain and improving activity of daily living after total hip replacement (THR) and total knee replacement (TKR) surgery. Though, information from studies conducting longer follow-ups and economic evaluations of exercise prior to THR and TKR is needed. The aim of the study was to analyse 12-month clinical effect and cost-utility of supervised neuromuscular exercise prior to THR and TKR surgery. Methods The study was conducted alongside a randomised controlled trial including 165 patients scheduled for standard THR or TKR at a hospital located in a rural area of Denmark. The patients were randomised to replacement surgery with or without an 8-week preoperative supervised neuromuscular exercise program (Clinical Trials registration no.: NCT01003756). Clinical effect was measured with Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS). Quality adjusted life years (QALYs) were based on EQ-5D-3L and Danish preference weights. Resource use was extracted from national registries and valued using standard tariffs (2012-EUR). Incremental net benefit was analysed to estimate the probability for the intervention being cost effective for a range of threshold values. A health care sector perspective was applied. Results HOOS/KOOS quality of life [8.25 (95% CI, 0.42 to 16.10)] and QALYs [0.04 (95% CI, 0.01 to 0.07)] were statistically significantly improved. Effect-sizes ranged between 0.09-0.59 for HOOS/KOOS subscales. Despite including an intervention cost of €326 per patient, there was no difference in total cost between groups [€132 (95% CI −3942 to 3679)]. At a threshold of €40,000, preoperative exercise was found to be cost effective at 84% probability. Conclusion Preoperative supervised neuromuscular exercise for 8 weeks was found to be cost-effective in patients scheduled for THR and TKR surgery at conventional thresholds for willingness to pay. One-year clinical effects were small to moderate and favoured the intervention group, but only statistically significant for quality of life measures. Trial registration ClinicalTrials.gov ( NCT01003756 ) October 28, 2009.

BackgroundThe clinical analgesic efficacy of iliopsoas plane block remains a subject of discussion. This study aimed to assess the analgesic efficacy of iliopsoas plane block under general anesthesia using multimodal analgesia.MethodsFifty-six adult patients who underwent elective primary hip arthroplasty were enrolled. Patients were randomized to receive either a single-shot iliopsoas plane block (10 mL 0.75% ropivacaine with 1:200 000 epinephrine) or a sham block (10 mL normal saline). All patients received general anesthesia, multimodal analgesia (preoperative buprenorphine patch, 5 µg/h), intraoperative intravenous dexamethasone (8 mg) and nefopam (20 mg), and round-the-clock acetaminophen and celecoxib. The primary outcome was the numeric rating scale pain score at rest 6 hour after surgery.ResultsIliopsoas plane block did not have a notable advantage over the sham block in terms of pain relief at rest, as assessed by the numeric rating scale score, 6 hour after total hip arthroplasty (iliopsoas plane block: median, 4.0; IQR, 2.0–5.8; sham: median, 5.5; IQR, 2.3–6.8; median difference, −1.0; 95% CI −2.0 to 0.0; p≥0.999). Linear mixed model analysis showed no differences in pain scores, opioid consumption, quadriceps strength, or quality of recovery between the groups.ConclusionsIliopsoas plane block did not improve postoperative analgesia following total hip arthroplasty under general anesthesia with a multimodal analgesic regimen. The blockade of sensory femoral branches supplying the anterior hip capsule using iliopsoas plane block may not yield additional benefits concerning patient outcomes in the aforementioned clinical context.Trial registration number NCT05212038, https://clinicaltrials.gov/ct2/show/NCT05212038

Background The aim of the study was to improve physical activity (PA), well-being and clinical outcome after total knee and hip arthroplasty through tailored activity counselling during inpatient rehabilitation. Methods 65 patients (aged 70.4 ± 7.3 years, BMI 28.5 ± 4.3) starting inpatient rehabilitation after primary knee or hip arthroplasty due to osteoarthritis were recruited and pseudo-randomized into an intervention (IG) and a control group (CG). Twice a week, the IG was encouraged to increase their daily step count by 5%. PA, e. g. number of steps, step frequency, or active minutes, was measured by step activity monitoring. Well-being and clinical outcome were assessed using the SF-36, Oxford Knee/Hip Score and Global rating of Change. Procedures were conducted at the onset of inpatient rehabilitation, and repeated one and 6 months after inpatient rehabilitation. Results Data sets were obtained from 49 patients (IG: n  = 23, CG: n  = 26). Both groups significantly increased their number of daily steps from the 1 month to the 6 months follow up after rehabilitation: CG: 9019 (95%CI: 7812, 10,226), IG: 9280 (7972, 10,588) and CG: 10921 (9571, 12,271), IG: 11326 (9862, 12,791) respectively. Additionally, well-being and clinical outcome improved significantly in both groups. No significant differences in physical activity, clinical outcome and well-being were found between the groups. Conclusions PA counselling during inpatient rehabilitation does not improve PA, well-being and clinical outcome in patients with primary knee or hip arthroplasty in addition to the rehabilitation program. PA interventions may be more effective after the completion of the inpatient rehabilitation phase. Trial registration DRKS DRKS00012682 . Registered retrospectively on 03–07- 2017.

Introduction Postoperative delirium (POD) is a common postoperative complication and is associated with numerous adverse outcomes. Advanced age and hip surgery are high risk factors for POD. Both remimazolam tosilate for injection and sevoflurane can be used as sedatives for the maintenance of general anesthesia, but the comparison of their impacts on the incidence of POD has not been reported. This study aims to compare the effect of remimazolam tosilate vernus sevoflurane on the incidence of POD in older patients undergoing total hip arthroplasty. Methods and analysis This is a two-arm, parallel, prospective, multicenter, randomized controlled trial. A total of 456 older patients at six clinical trial centers in China will be randomly assigned in a 1:1 ratio to receive general anesthesia with remimazolam tosilate or sevoflurane as sedative. The primary outcome measure is the prevalence of POD during the first 4 postoperative days. Secondary outcomes include cognitive function [Mini-Mental State Examination (MMSE)], perioperative pain degree [Visual Analogue Scale (VAS)], postoperative nausea and vomiting (PONV) within 4 days after surgery, recovery time after drug withdrawal, the amount of vasoactive drugs used during operation, length of hospital stay, and in-hospital complications. Ethics and dissemination The Research Ethics Committee of Qilu Hospital of Shandong University has approved the study protocol (REF: KYLL-202206-25), which is applicable to all research centers. Participant recruitment begins in August 2022. Written informed consent will be obtained from each patient before randomization. The findings will be published in an international peer-reviewed medical journal. Trial registration The trial has been registered at the Chinese Clinical Trial Registry: ChiCTR2200062455; date of registration: 2022-08-08.

Background Total hip arthroplasty (THA) is a proven surgical option for patients with end-stage osteoarthritis in terms of improved function and pain relief. A prospective study was conducted to examine and evaluate the effect and impact of zolpidem postoperatively on the sleep quality, pain alleviation, and quality of life of patients who underwent total hip arthroplasty. Methods A total of 160 patients was randomized 1:1 to receive either zolpidem or placebo 2 days preoperative to 5 days postoperatively. Pain scores using visual analog scale (VAS), sleep quality using Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale, quality of life using QoR-40, and Hip disability and Osteoarthritis Outcome Score were recorded. The total amount of opioid analgesics and antiemetics taken was recorded as well. Results Patients in the intervention group had higher VAS score and took less analgesic and antiemetic. Moreover, the study demonstrated that QoR-40 was higher and Hip disability and Osteoarthritis Outcome Score had relatively lower mean value ( P  < 0.05) in the treatment group. Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale were also lower in the treatment group ( P  < 0.05). Conclusion Patients taking zolpidem achieved greater improvement in the quality of life and reported better satisfaction. The study demonstrated zolpidem 10 mg can improve sleep quality effectively, relieve pain, increase early range of motion and muscle strength, reduce the perioperative anxiety and depression, and improve perioperative experience and satisfaction, thereby reducing the hospital stay and medical costs and promote the rapid recovery and quality of life. Trial registration The trial was registered on Chinese Clinical Trial Registry, ChiCTR-IOR-16007861 .

Background To date, few knowledge is available about safety and effectiveness of one-staged combined hip and knee arthroplasty. The aim of our study was to evaluate, in a comparative fashion, complications and outcomes in patients who underwent one-staged hip and knee arthroplasty. Methods Forty-two patients were enrolled and allocated into two groups of 21 patients each: one-staged hip and knee arthroplasty (group A) and two-staged hip and knee arthroplasty (group B). The follow-up averaged 50.2 months. Postoperative complications and implant survivorship were assessed prospectively. Outcomes were evaluated with Harris Hip score (HSS), Western Ontario Mc-Ministry score for the hip (h-WOMAC), Knee Society score (KSS), and Western Ontario Mc-Ministry knee score (k-WOMAC). Hip and knee range of motion (ROM) were measured both preoperatively and at the last follow-up. Results Two (9.5%) patients in group A and three (14.3%) patients in group B developed complications ( P  = 0.8). Although a significant decrease in postoperative haemoglobin (Hgb) values was found in group A patients during the hospital stay, no differences in blood transfusions were found ( P  = 0.8). No significant differences were found comparing clinical-functional outcomes between the two groups, while a significant reduction of hospital length of stay was shown in group A patients. Conclusions One-staged combined hip and knee arthroplasty could be considered in patients with co-existing severe hip and knee osteoarthritis, providing similar complications and mid-term outcomes of two-staged procedures. However, the reproducibility safety and reliability of these procedures should be confirmed in prospective comparative randomised trials with more numerous patients. Trial registration Retrospectively registered

Purpose The present study was designed to evaluate the efficacy and safety of combined use of intravenous (IV) TXA administration and topical intraarticular tranexamic acid (TXA) strategy in patients aged over 70 undergoing total hip arthroplasty (THA). Methods One hundred eighty patients were randomized into three groups, including an IV group, a local group, and a combined group. Patients were administrated with 15 mg/kg of IV-TXA in the IV group, 2 g TXA in the topical group, or 15 mg/kg IV-TXA combined with 2 g TXA in the combined group. Total blood loss (TBL), maximum hemoglobin drop, the transfusion rate and the number of allogeneic blood units, and the incidence of deep venous thrombosis (DVT), and pulmonary embolism (PE) were recorded and analyzed. Results TBL was 757.75 ± 188.95 mL in the combined group, which was significantly lower than in the IV group (892.75 ± 218.47) or the topical group (1015.75 ± 288.71) ( p  = 0.015, p  = 0.001 respectively). The mean values of maximum hemoglobin drop in the combined, IV, and topical groups were 2.67 ± 0.42, 3.28 ± 0.52, and 3.75 ± 0.62 g/dL, respectively, with a significant intergroup difference ( p  < 0.001 for all). PE was not detected within 1 month after the surgery. Asymptomatic DVT was reported in 1 patient of the IV group, and in 2 patients from the combined group, while the difference was not statistically significant. Conclusions Compared to intravenous or topical use of TXA, the combined therapy effectively decreased total blood loss and reduced the transfusion rate, simultaneously possessed the same degree of safety in primary THA patients aged over 70.

Background Dislocation following total hip arthroplasty has to date not been resolved satisfactorily. Previous work has shown that using a less-invasive adaption of Bauer’s lateral transgluteal approach with capsular repair significantly reduces dislocation rates in primary total hip arthroplasty. The aim of this retrospective cohort study was to assess whether this approach also helps to reduce the dislocation rate in revision total hip arthroplasty. Methods We analyzed revision total hip arthroplasty cases performed between 10/2005 and 12/2013 in our department, classifying capsular repair cases as study group and capsular resection cases as control group. The WOMAC score, the dislocations and the revisions were observed. Results A total of 259 cases were included, 100 in the study group and 159 in the control group. In the 12-month follow-up, dislocation rates were significantly lower in the study group (3%, n  = 3) compared to the control group (21.4%, n  = 34; p  = 0.001). Overall follow-up periods were 49 and 79 months, revision frequencies were 10 and 29%, pain improvements were 5.5 compared to 4.4 and the WOMAC global scores averaged 2.0 ± 2.1 and 2.9 ± 2.6 for the study group and the control group, respectively. Conclusion The modified, less-invasive, lateral transgluteal approach with capsular repair was accompanied by an 86% reduction in dislocation rates when compared to the conventional technique with capsular resection via the anterolateral Watson-Jones-approach. Capsular repair is possible in about 60% of the revision total hip arthroplasty cases, may be considered as beneficial to avoid dislocation and can therefore be recommended.