Abstract:
Background: For some time, optimized perioperative pathway protocols have been implemented in orthopedic surgery. In our hospital an accelerated clinical pathway has been successfully in effect for several years, focused on safely decreasing patients’ length of stay and increasing their function at the time of discharge. The aim of the present project was to evaluate whether a further optimization is even more promising regarding early postoperative outcome parameters.\r
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Materials and Methods: Prospective, parallel group design in an Orthopaedic University Medical Centre. 143 patients, scheduled for unilateral primary total knee replacement (TKR) under perioperative regional analgesia were included. 76 patients received a Standard Accelerated Clinical Pathway (SACP). 67 patients received an Optimized Accelerated Clinical Pathway (OACP) including patient-controlled regional analgesia pumps, ultra-early/doubled physiotherapy and motor driven continuous passive motion machine units. Main measures were early postoperative pain on a visual analogue scale, consumption of regional anaesthetics, knee range of motion, time out of bed, walking distance/stair climbing, circumference measurements and Knee Society Scores of the operated leg. Patients in both groups were checked for a possible discharge by a blinded orthopedic surgeon on the 5th and 8th postoperative (po) day, using a discharge checklist including the KATZ Index of Independence in Activities of Daily Living, standard requirements for pain at rest/mobilization, walking distance and regular wound healing. A potential discharge was only approved if the patient was able to meet all six criteria from the discharge checklist. Re-admission within 6 weeks after discharge from hospital was registered.\r
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Results: Patients within the OACP had significant benefits regarding stair climbing/walking distance/ time-out-of bed/circumference measurements of the thigh/Knee Society function score on the 5th po day and stair climbing/circumference measurements of the thigh on the 8th po day, and reduction of the consumption of regional anaesthetics. No significant reduction in length of stay was observed. \r
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Discussion: Early postoperative functional process indicators tended to be higher within the OACP group, but the main effects flatten in the course of the first eight postoperative days. Further, prospective randomised clinical trials with uniform, objective discharge criteria are needed.\r

Abstract:
Background: Randomized, controlled trials (RCTs) are generally accepted as the “gold standard” for the provision of the most unbiased measures of the efficacy of interventions but are often criticized for the lack of external validity. We assessed the external validity of a RCT examining the efficacy of local infiltration analgesia (LIA) compared with continuous epidural infusion after total knee arthroplasty (TKA) \r
Methods: During a one-year period, all patients consecutively admitted for elective, unilateral, primary TKA were identified as potential participants. All underwent eligibility screening to determine who were eligible for participation in a randomized controlled trial. We investigated the distribution of preoperative characteristics and postoperative variables among excluded patients, non-consenters, and enrolled and randomized participants. \r
Results: In all 157 patients were identified as potential participants. Only 49 patients (31%) were enrolled and randomized. A significant difference was found in both preoperative characteristics and clinical outcome variables. Non-participants were less healthy and needed more help from the home care service than did participants. Furthermore, they were hospitalized longer. \r
Interpretation: Our findings demonstrate the importance of reporting the results of RCTs in a way that allows clinicians to judge to whom the results can reasonably be applied. \r
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Abstract:
【Introduction】\r
Nociceptive and neuropathic components both contribute to chronic pain. Since these components require different pain management strategies, correct pain diagnosis before and during treatment is important.\r
Freynhagen et al. (2006) reported that they had developed and validated the pain-DETECT questionnaire (PD-Q) to detect neuropathic components in chronic low back pain patients. They also reported that 37% of unselected cohort of chronic LBP patients had predominantly neuropathic pain. However, the extent to which neuropathic components relate to the pathomechanism of pain deriving from osteoarthritis of hip joint remains unknown. \r
The purpose of this study was to utilize PD-Q to investigate the relationship between neuropathic components and pain deriving from osteoarthritis of the hip joint. \r
【Methods】\r
Between March and August 2010, 125 patients with osteoarthritis of hip joint completed PD-Qs about their pain. From this data set, we investigated whether or not the patients’ pain contained neuropathic components.\r
【Results】\r
Only 6.4% of the patients had a score ≧19, indicating that a neuropathic component was likely (＞90%). Conversely, 79.2 % had a score ≦12, indicating that a neuropathic component was unlikely (＜15%). For the remaining 14.4% with an intermediate score (13-18), the presence of a neuropathic component remained uncertain.\r
【Conclusion】\r
In this set of patients with osteoarthritis of hip joint, the PD-Q responses indicated that only a small percentage (6.4%) were likely to have a neuropathic component to their hip pain.\r
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Abstract:
Introduction: Viscosupplementation is used widely to provide symptomatic relief to patients with knee OA. This study aimed to compare the efficacy and safety of the standard (3x2ml) and single (1x6ml) dosing regimens of hylan G-F 20\r
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Methods: Prospective, randomized, blinded (reviewers), comparative independent study. Inclusion criteria was OA knee pain e 60mm on a 100mm VAS; no prior intra articular (IA) injection. Patients were randomised to recieve 1 x 6mL or 3 x 2mL hylan G-F 20. Follow-up at 1, 6, 12, 26 and 52 weeks. Analgesics prohibited for 24 hours prior to follow-up assessments and NSAID_s for 26 wks. All adverse events (AE) were recorded. Primary outcome measure: Target knee pain (VAS) at 26 weeks. Secondary outcome measures included WOMAC, Oxford knee score, SF12\r
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Results: 412 patients were randomized (1 x 6mL N=194, 3 x 2 mL N=218). There were no significant differences in age, gender or grade of OA. Injection and/ or treatment-related AE (all mild/moderate) were reported in 10.5% (3 x 2 mL) and 9.1% (1 x 6 mL) of patients Significant pain reduction was observed in both groups at 26 weeks (3 x 2 mL: 50% (mean) decrease, 1 x 6mL: 45% ). There were no significant differences between groups for any of the primary or secondary outcome measures at 26 weeks.\r
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Discussion and Conclusion: Single dose of 6 mL hylan G-F 20 offer comparable safety and efficacy to 3 x 2 mL at 26 weeks. It provides both the patients and physicians a choice with the potential additional benefits of reduced operational costs.\r

Abstract:
A programme of enhanced care Fast track total hip replacement was introduced in our institution in 2003 with further refinement and improvement over time as we gained experience. Optimization of perioperative logistics and post-op rehabilitation of all patients who underwent total hip arthroplasty (THR) has reduced the average length of in-hospital stay. We reviewed all patients on our hip database to assess if the reduction in length of stay had any impact on outcome scores and re-admission rates.\r
Material & Methods – All 105 patients with THR in 1999 and 200 consecutive hips in 2004 and 2009 were included in the study. All patients had a cemented Exeter total hip replacement. The average length of stay along with the re-admission rate at 30 days was collected from the hospital records and harris hip scores were recorded pre-operatively and one year post-operatively. Standard statistical methods were used.\r
Results - The age group and the sex ratio of the three groups were comparable. The average length of in-hospital reduced from 11.9 in 1999 to 4.3 days in 2009. One patient from 1999, five from 2004 and 2 patients from 2009 died before completion of data collection. Only one of these deaths was in the immediate post-operative period. More than 80% had complete follow up. There was no difference in the re-admission rates, complications and their rates in any of the groups. The difference in the outcome scores was not statistically different. \r
Conclusion – substantial reduction in the length of stay following hip replacements does not appear to increase the risk of complications or the outcome at one year.\r