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