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ABSTRACTBackground Chronic postsurgical pain (CPSP) may increase the risk of postoperative cognitive dysfunction (POCD) directly or by negatively impacting mobility. A comprehensive measure of satisfaction with surgery that accounts for ability to perform activities might be even more strongly associated with POCD. There might be complex mechanisms underlying the interplays between postoperative pain and cognition.Aims The primary objective is to explore whether CPSP at 6 months is associated with POCD (≥2-point decline in the Montreal Cognitive Assessment [MoCA] compared to preoperative) at 12 months. Secondary objectives are to explore the association between satisfaction with surgery and POCD, the role of pain medications (opioids) in the association between CPSP and POCD, the role of patient preoccupation/optimism and coping in determining the effect of pain on cognition, and the hypothesis of neurogenesis interference as an underlying mechanism.Methods We will prospectively recruit ≥100 patients ≥50 years old undergoing elective total knee/hip arthroplasty. Sociodemographic characteristics, comorbidities, frailty, pain, and pain medications will be assessed preoperatively. The Somatic Preoccupation and Coping questionnaire will be administered preoperatively and 4 to 6 weeks postoperative. Pain and the Self-Administered Patient Satisfaction Scale will be measured at 3 and 6 months. MoCA and neuropsychological tests will be administered at baseline, 4 to 6 weeks, and 6 and 12 months. Blood will be longitudinally collected for biomarker analysis.Progress Forty-six participants have been enrolled in the study so far.Conclusion ArthroCaP will provide preliminary data on the association of CPSP and patient satisfaction with POCD and underlying mechanisms. It will inform larger confirmatory and interventional studies to enhance the benefits of surgery.

Background We hypothesize that the addition of local infiltration analgesia (LIA) to a multimodal pain protocol will reduce the total amount of opioids consumed for acute pain control post total knee arthrolplasty (TKA). Methods This study was a retrospective, matched pair study including patients who had primary TKA. All patients included in the analysis had preoperative oral celecoxib and acetaminophen, had single-dose spinal anesthetic with intrathecal morphine, and had intravenous patient-controlled analgesia with an opioid agent in addition to gabapentin and celecoxib in the first 48 h. Patients whose charts were excluded from the study had revision TKA, received opioid therapy prior to the surgery, were classified as American Society of Anesthesiology (ASA) IV, and had general anesthesia. Fifty patients who underwent TKA and had LIA were matched for age, body mass index (BMI), and gender with patients who did not receive LIA. The primary outcome measures were total doses of opioids consumed post TKA. Results Patients receiving LIA consumed on average significantly less intravenous (IV) morphine equivalents than patients not receiving LIA, with a mean difference (±SD) of 88.9 ± 15.6 mg IV morphine equivalents. Furthermore, pain control was better in the LIA group. The incidences of nausea and vomiting, pruritis, and excessive sedation were higher in the non-LIA group compared to the LIA group. There was no difference in the hospital length of stay between both groups. Conclusions The addition of LIA to our multimodal pain protocol for TKA was associated with a reduction in total opioid consumption.

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Résumé Les douleurs chroniques postchirurgicales globales touchent 10 à 30 % des personnes opérées. Après chirurgie du genou, elles varient de 16 à 20 %. Parmi ces douleurs qui persistent sans étiologie infectieuse, problèmes mécaniques ou algodystrophie, beaucoup sont liées à une douleur neuropathique en rapport avec une lésion nerveuse peropératoire ou un dysfonctionnement de la modulation de la douleur avec sensibilisation centrale. Les facteurs de risque cliniques et la physiopathologie sont des sujets en pleine évolution avec un impact des douleurs préopératoires, du contexte de douleurs plus diffuses, de la sévérité des douleurs postopératoires immédiates, de l’existence de troubles anxio-dépressifs ou cognitifs comme le catastrophisme et enfin des comorbidités. Le diagnostic, qui est clinique, doit être le plus précoce possible pour améliorer les chances d’amélioration. La prise en charge repose sur des stratégies préventives périopératoires et le traitement des douleurs chroniques neuropathiques. Les traitements locaux avec la neurostimulation transcutanée et les emplâtres de lidocaïne associés au tramadol peuvent être complétés en cas d’efficacité insuffisante par des traitements antidépresseurs ou antiépileptiques. Les patchs de capsaïcine arrivent en 3 e ligne et les opioïdes forts en dernière ligne de traitement. Une prise en charge rééducative et des exercices physiques sont souhaitables. Une prise en charge psychologique et/ou cognitivocomportementale peut être nécessaire en fonction de l’évaluation du patient. Chronic postsurgical pain (CPSP) is experienced by 10 to 30% of individuals after classical operations. After knee surgery, epidemiology of CPSP varies between 16 to 20% of patients. Among these persistent pains without infection, mechanic injury or algodystrophy, the frequency of neuropathic pain is important. Neuropathic pain is due to nerve injury or impaired pain modulation with central sensitization. Variables that were commonly associated with a greater risk of chronic postoperative pain included greater preoperative pain, other pain sites, acute postoperative pain severity, psychological factors indicating negative affect, cognitive factors as catastrophism and comorbidities. The diagnosis is clinic and early detection is the better way to reduce chronic pain. The management of CPSP is based on preventive strategies and treatment of neuropathic pain. After knee surgery, first-line treatment of neuropathic pain coud be transcutaneous electrical nerve stimulation and lidocain patch, associated to tramadol. If insufficient, the recommended treatments are antidepressants, pregabalin and gabapentin, then capsaicin high-concentration patches in thrird line and strong opioids in last line. A rehabilitation programme and physical activity are strongly recommended. Several intervention strategies exist to address psychological distress or cognitive and emotional variables. [ABSTRACT FROM AUTHOR]

Résumé Introduction L’arthroplastie du genou occasionne d’importantes pertes sanguines. Différentes techniques d’épargne transfusionnelle existent dont la retransfusion de sang épanché de redon. Certaines études remettent en cause la qualité de ce sang et notamment sa capacité à coaguler. Elles utilisent des tests d’hémostase « statiques » qui reflètent de manière très incomplète la réalité, contrairement aux méthodes viscoélastiques. L’objectif principal de cette étude était d’évaluer le profil thromboélastométrique par ROTEM ® du sang épanché en le comparant au sang veineux du patient. Patients et méthodes Il s’agissait d’une étude observationnelle, prospective et monocentrique effectuée sur 3 mois en 2013. L’accord du CPP et le consentement des patients ont été obtenus au préalable. Tous les patients majeurs ayant bénéficié d’une arthroplastie totale primaire du genou avec mise en place d’un redon récupérateur ont été inclus. Un profil thromboélastométrique et un bilan biologique standard (hémoglobine, plaquette, TP, TCA, fibrinogène) ont été réalisés sur le sang veineux du patient et sur le sang épanché du redon récupérateur en SSPI. Résultats Vingt patients ont été inclus. La durée médiane de chirurgie était de 93 minutes. Treize patients (65 %) ont reçu de l’acide tranexamique en peropératoire. Le volume médian de sang épanché a été de 225 mL. Deux patients (10 %) ont bénéficié d’une retransfusion. L’analyse du sang épanché a montré un déficit majeur en facteurs de coagulation en biologie standard (TP < 10 %) et l’absence de formation de caillot en thromboélastométrie quel que soit l’activateur utilisé (In-tem ® , Ex-tem ® , Fib-tem ® ou Ap-tem ® ). Par rapport au sang veineux, le sang du redon avait un taux d’hémoglobine significativement plus bas : 8,8 vs 13,5 g/dL ( p < 0,0001). La transfusion allogénique a concerné 5 % des patients. Discussion Dans ce travail, nous avons confirmé que le sang de redon était incoagulable probablement en relation avec un mécanisme multifactoriel associant un déficit en facteur et une activation de la fibrinolyse. Introduction Knee arthroplasty causes significant blood loss. Different blood-saving measures exist like retransfusion of unwashed salvaged blood. Some studies question the quality of this blood and in particular its ability to clot. These studies use “static” coagulation tests reflecting only partially the reality, unlike viscoelastic methods. The main objective of this study was to evaluate the salvaged blood thromboelastometric profile using ROTEM ® system and to compare these results with patient venous blood. Materials and methods We performed an observational, prospective, single-center study conducted over 3 months in 2013. Agreement of local ethical committee and patient consent were obtained beforehand. All adult patients who underwent a primary total knee arthroplasty were included. A thromboelastometric profile and standard laboratory tests (hemoglobin, platelets count, PT, aPTT, fibrinogen) were performed in the same time on patient venous blood and on unwashed salvaged blood in the PACU. Results Twenty patients were included. The median duration of surgery was 93 minutes. Thirteen patients (65%) received tranexamic acid during procedure. The median volume of shed blood was 225 mL. Two patients (10%) received a reinfusion. Analysis of shed blood showed a major deficiency of clotting factor in standard biology (PT < 10%) and an absence of clot formation in thromboelastometric test (In-tem ® , Ex-tem ® , Fib-tem ® or Ap-tem ® ). Compared to venous blood, shed blood had significantly lower hemoglobin levels: 8.8 vs 13.5 g/dL ( P < 0.0001). Allogenic transfusion concerned 5% of patients. Discussion In this work, we confirmed that shed blood was naturally uncoagulable probably due to a multifactorial mechanism involving a major clot factor deficiency and an activation of fibrinolysis. [ABSTRACT FROM AUTHOR]

Copyright of Lettre de Medecine Physique et de Readaptation is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: Aim: Tranexamic acid (TxA) reduces total blood losses (TBL) and allogenic transfusion (TH) after total knee arthroplasty (TKA). TBL can be external (surgical field, drains), or hidden (haematomas). Haematomas induce pain and limit postoperative rehabilitation. The aim of the study was to evaluate if TxA reduces haematomas and pain after TKA. Study design: Prospective non-randomized study. Method: After ethical committee approvement and written informed consent, the patients planned for a primary TKA were included (control group followed by a TxA group, 15mg/kg before incision and at skin closure). General anaesthesia and analgesia were standardized (sciatic block, continuous femoral block, ketamine, ketoprofene, paracetamol, PCA with morphine). Volume of haematomas=TBL (calculated based on haemograms performed the day before surgery, and at postoperative day 5, and on transfusions)–measured external bleeding. Patients were followed up for 8days, and at postoperative day 180 (by phone). Fifty patients per group allowed the detection of a 50% morphine sparing at day 8 (α=0.05 and β=0.2), and a 25% reduction of haematoma volumes at day 5. Results: Perioperative data, pain scores and functional parameters (until day 180) were not different between control group patients (n =52) and TxA group patients (n =55): morphine consumption at day 8 was respectively 35±32 and 42±38mg (P =0.29). Yet, TxA reduced hematoma volumes (526±202 versus 337±165mL of red blood cells, P <0.0001) and clinically apparent hematomas. Morphine consumptions at day 8 and haematoma volumes were not correlated. Conclusion: After TKA, TxA reduces the volume of hematomas, without any improvement in analgesia and rehabilitation until the sixth postoperative month. [Copyright &y& Elsevier]

Résumé: Objectifs: Nous avons analysé l’évolution clinique et radiologique à long terme de 68 prothèses totales du genou consécutives chez 50 patients atteints de polyarthrite rhumatoïde. Méthodes: Au cours d’un suivi dont la durée moyenne était de 11,2±1,2 ans (éventail entre 9,7 et 13,7 ans) toutes les révisions (reprises) de prothèses ont été incluses. L’évolution clinique et radiologique a été suivie rétrospectivement pour 37 genoux chez 28 patients encore en vie. Tous les autres patients qui sont décédés sans révision ont été pris en compte au moment du dernier contrôle de suivi et aucun patient n’a été perdu au cours du suivi. Une révision s’est imposée pour 13 genoux (19 %, un révisé deux fois), avec un taux global d’infection profonde de 1,47 %. Résultats: Le taux de survie était de 81,6±0,05 à 12 ans en considérant toute révision ou extraction de la prothèse comme point final. Aucune différence significative n’a été observée entre les fixations avec ou sans ciment ou celles hybrides (Log rank 0,2544). Le score moyen IKS de la Knee Society était respectivement de 77,2 points cliniques (éventail de 40 à 95 points) et 75,3 points fonctionnels (éventail de 30 à 100 points) au contrôle final. L’indice de masse corporelle (IMC) était 25,9 au moment de la chirurgie et 25,3 au suivi (n.s.). Il n’y avait aucune corrélation entre l’IMC, l’âge, le côté, le sexe et la fréquence de révision. Aucune arthroplastie n’était à risque de retrait ou de révision au suivi. Conclusions: L’étude montre dix à 12 années de résultats cliniques et radiologiques pour la prothèse du genou PCA chez des patients atteints de polyarthrite rhumatoïde sans préférence pour la méthode de fixation ou le poids du patient. [Copyright &y& Elsevier]

Abstract: The objective of rehabilitation after arthroplasty is the restoration of satisfactory joint amplitude and muscular strength. The objective of this study was to determine the reasons for hospitalization for rehabilitation after knee arthroplasty, duration of stay and perioperative morbidity. The retrospective and descriptive study included 90 patients. The average age of patients was 74.5 years. A total of 84% of patients underwent primary arthroplasty and 16% secondary arthroplasty, with 7% undergoing bilateral arthroplasty. Of the patients, 88% displayed a comorbidity; 16% a deficit in flexion or extension. A total of 28% were dependants and 43% lived alone at home. Local adverse events occurred in 48% of the patients and general adverse events in 59%; deep venous thrombosis and/or pulmonary embolism were the most frequently described events (15.5%). The duration of stay for rehabilitation was 8.8 days in surgery, and 19.9 days in a rehablilitation center. The mean duration of stay was the greatest for patients with bilateral arthroplasty, those with a serious complications and older patients. The factors that determine hospitalization for rehabilitation after knee arthroplasty include older age, with comorbidity held constant; bilateral or secondary arthroplasty; level of disability; degree of dependence; living alone at home; and complications. A short stay in surgery followed by a short stay in rehabilitation center is possible with a network management. [Copyright &y& Elsevier]

Abstract: Objectives. – To evaluate the usefulness of monitoring C-reactive protein (CRP) level and leukocyte count for early diagnosis of infection following orthopedic surgery. Method. – A cohort of 179 patients was followed: group 1 comprised 128 patients undergoing lower limb arthroplasty, group 2 comprised 29 patients undergoing lower limb surgery without implant, and group 3 comprised 22 patients undergoing spinal or upper limb surgery. CRP level and leukocyte count were systematically measured on admission and then once a week for 4 weeks. Wound infections, other infections, wound disconnection without infection and hematoma were noted. CRP level and leukocyte count were monitored postoperatively in patients with and without complications. Results. – CRP level was 4- to 8-fold above the normal range at the first postoperative measurement but normalized within the next 3 weeks (reaching normal levels by the 30th postoperative day, on average). In the 7 cases of wound infection (WI), the CRP level rose to 28-fold above normal and was significantly different from that in without infection or with intercurrent infection (P <0.01). A receiver operating characteristic (ROC) curve was established for CRP level, and for a value of 60 (12-fold above the normal range) the sensitivity was 100%, the specificity 83.6% and the negative predictive value 100%. The variation in leukocyte count was minor, with a significant difference noted between only patients not infected or those with WI (P <0.05). Discussion and conclusions. – Measurement of CRP level can be used for early diagnosis of wound infection. In the case of strong clinical suspicion or in the presence of high risk factors, when the level is at 12-fold or more above the normal range, the diagnosis of infection is highly probable. [Copyright &y& Elsevier]

Introduction: Knee arthroplasty causes significant blood loss. Different blood-saving measures exist like retransfusion of unwashed salvaged blood. Some studies question the quality of this blood and in particular its ability to clot. These studies use "static" coagulation tests reflecting only partially the reality, unlike viscoelastic methods. The main objective of this study was to evaluate the salvaged blood thromboelastometric profile using ROTEM® system and to compare these results with patient venous blood., Materials and Methods: We performed an observational, prospective, single-center study conducted over 3 months in 2013. Agreement of local ethical committee and patient consent were obtained beforehand. All adult patients who underwent a primary total knee arthroplasty were included. A thromboelastometric profile and standard laboratory tests (hemoglobin, platelets count, PT, aPTT, fibrinogen) were performed in the same time on patient venous blood and on unwashed salvaged blood in the PACU., Results: Twenty patients were included. The median duration of surgery was 93 minutes. Thirteen patients (65%) received tranexamic acid during procedure. The median volume of shed blood was 225 mL. Two patients (10%) received a reinfusion. Analysis of shed blood showed a major deficiency of clotting factor in standard biology (PT<10%) and an absence of clot formation in thromboelastometric test (In-tem®, Ex-tem®, Fib-tem® or Ap-tem®). Compared to venous blood, shed blood had significantly lower hemoglobin levels: 8.8 vs 13.5 g/dL (P<0.0001). Allogenic transfusion concerned 5% of patients., Discussion: In this work, we confirmed that shed blood was naturally uncoagulable probably due to a multifactorial mechanism involving a major clot factor deficiency and an activation of fibrinolysis., (Copyright © 2015 Elsevier Masson SAS. All rights reserved.)

Summary: Total hip arthroplasty (THA) and total knee arthroplasty (PTG) are surgical interventions aiming at functional improvement. They therefore cannot accommodate any “collateral damage” produced, notably by symptomatic thromboembolic events (STE). Use of the necessary thromboprophylaxis has made STEs rare (<3% after THA and 2% after TKA). Pulmonary embolism (PE) is exceptional (0.3%) and only accounts for 15% of the deaths occurring in the 1st postoperative month. However, atherothrombotic disease is significantly associated with thromboembolic venous disease. The causes of STEs are mechanical, directly related to surgical maneuvers, but also biological (familial or acquired thrombophilia, hypercoagulability, particularly associated with hip surgery). Delayed resumption of walking, which promotes venous stasis, has been improved by modern pain management techniques. There is consensus on the need to prolong thromboprophylaxis after THA, but it is more controversial after TKA and depends on the added risk factors. In France, prolonged prevention is widespread. The relatively low STE rate should be put into perspective with the risk of hemorrhage. The surgeon should be particularly attentive to the risk of bleeding at the operative site because it generates a risk of sepsis, and a risk of stiffness for TKA. The risk of hemorrhage essentially results from the misuse of all the anticoagulants, particularly observed with the anti-vitamin K medications because their use is more restricted. The risk of hemorrhage has become quite comparable to the risk of thromboembolism with prophylaxis. To prevent this event, the prescriber must know the characteristics of each drug : Tmax, half-life, mode of elimination, as well as the risk of accumulation in the patient receiving such treatment (creatinine clearance). Currently, the thrombohemorrhagic risk for each patient must be assessed. Per os treatment with Dabigatran etexilate is highly advantageous because it is easy to use, there is no thrombopenia induced by heparin, and there is no need for complementary monitoring exams, thus reducing costs. Efficacy in terms of prevention and hemorrhagic risk, demonstrated in phase II studies, must be confirmed by widespread used in real-life conditions. [Copyright &y& Elsevier]