Pagnano, Mark W.

Background: The U.S. Food and Drug Administration has approved a bupivacaine and meloxicam extended-release (ER) intra-articular injection for pain during total knee arthroplasty (TKA). However, the real-world evidence with regard to analgesic efficacy of that medication has been limited. This randomized clinical trial investigated the efficacy of this new medication compared with our standard periarticular injection for postoperative analgesia after primary TKA. Methods: Eligible patients undergoing primary, unilateral TKA for osteoarthritis at our academic center were enrolled. Patients were blinded and were randomized 1:1 to the bupivacaine-meloxicam ER (ZYNRELEF) injection group or the standard injection (ropivacaine, ketorolac, epinephrine) control group. A standardized, multimodal analgesic pathway was implemented. Numeric Rating Scale (NRS) pain scores and tallies of opioid consumption were collected. The primary outcome was the area under the curve (AUC) for NRS pain, adjusted for opioid consumption, over 72 hours. The minimal clinically important difference was considered to be 30%. Power analysis determined a minimum of 44 patients per group. The final groups included 53 patients in the experimental group and 48 patients in the control group. Results: Similar postoperative analgesia was observed, with an AUC for the adjusted NRS pain score up to 72 hours of 331 in the experimental group and 373 in the control group (p = 0.09). The mean maximum NRS pain scores were similar and reflected good, but not complete, analgesia. Scores were 3 to 5 on the day of the surgery, 4 to 6 on postoperative day (POD) 1, 5 to 6 on POD 2, and 4 to 5 on POD 3 (p > 0.05). One patient in the experimental group and 2 patients in the control group had early postoperative complications, none of which was deemed to be related to the analgesic choice. Conclusions: This randomized clinical trial demonstrated similar analgesia with a bupivacaine-meloxicam ER solution and a standard periarticular injection up to 72 hours after primary TKA. Cost, reimbursement, and convenience may ultimately prove to be more important than analgesic differences when choosing between these 2 effective options for managing postoperative pain. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

AimsThe purpose of this study was to directly compare the Modular Dual Mobility (MDM) Mobile Bearing Hip System (Stryker, USA) and large femoral heads (LFHs) in revision total hip arthroplasties (THAs) at mid-term follow-up, with specific emphasis on survival free of re-revision for dislocation, any re-revision, dislocation, and the risk of metal-related complications.MethodsWe identified 299 revision THAs performed at a single tertiary care academic institution from March 2011 to July 2014. Aseptic loosening of the acetabular component (n = 65), dislocation (n = 58), and reimplantation as part of a two-stage exchange protocol (n = 57) were the most common reasons for index revision. MDM constructs were used in 123 cases, and LFHs were used in 176 cases. Mean age was 66 years (28 to 93), mean BMI was 31 kg/m2 (18 to 55), and 45% (n = 136) were female. Mean follow-up was seven years (2 to 12).ResultsThe ten-year survival free of re-revision for dislocation was 99% (95% CI 95 to 100) in the MDM cohort and 91% (95% CI 84 to 96) in the LFH cohort, with a significantly increased risk of re-revision for dislocation in the LFH cohort (HR 7.1 (95% CI 1.3 to 40.8); p = 0.023). The ten-year survival free of any re-revision was 92% (95% CI 82 to 99%) in the MDM cohort and 84% (95% CI 74 to 90) in the LFH cohort with a significantly increased risk of any re-revision in the LFH cohort (HR 2.6 (95% CI 1.1 to 5.9); p = 0.024). The ten-year survival free of any dislocation was 95% (95% CI 85 to 99) in the MDM cohort and 87% (95% CI 78 to 92) in the LFH cohort with a significantly increased risk of any dislocation in the LFH cohort (HR 2.7 (95% CI 1.1 to 6.3); p = 0.028). There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.ConclusionIn this head-to-head comparison, revision THAs with a MDM construct safely and effectively lowered the risk of re-revision for dislocation, any re-revision, and any dislocation compared to LFH at mid-term follow-up. There were no re-revisions or reoperations for metallosis or corrosion in the MDM cohort.Cite this article: Bone Joint J 2025;107-B(1):58–64.

Marlex mesh reconstruction of the extensor mechanism following total knee arthroplasty (TKA) has demonstrated excellent early results. The purpose of the present study was to evaluate longer-term results of Marlex mesh reconstruction of the extensor mechanism in 93 TKAs. Seventy-seven reconstructions were aseptic, and 16 were performed as part of a 2-stage exchange for the treatment of infection. Mean follow-up was 8 years. Twenty-eighty patients experienced mesh failure. Seventeen failures were treated with mesh revision (8 for patellar tendon rupture, 7 for quadriceps tendon rupture, and 2 for symptomatic lengthening). The 10-year cumulative incidence of mesh revision for mesh failure was 20%. Extensor lag improved by a mean of 28°, with a mean extensor lag of 9° at most recent follow-up. At a mean follow-up of 8 years, Marlex mesh reconstruction was a durable and reliable technique to treat both aseptic and septic ruptures of the extensor mechanism. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Abstract Background Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. Methods This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. Results One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection ( P = 0.016; Hodges–Lehmann median difference [95% CI] = −1 [−2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal −2 [−3 to −1]; P < 0.001; average −0.8 [−1.3 to −0.2]; P = 0.003; and liposomal bupivacaine: maximal −3 [−4 to −2]; P < 0.001; average −1.4 [−2.0 to −0.8]; P < 0.001). Conclusions Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

Abstract In an effort to facilitate the use of interference screw fixation in the tibia, a method to orient the tibial tunnel termed the “N + 7 Rule” was prospectively applied to 60 consecutive endoscopic anterior cruciate ligament reconstructions performed by a single surgeon. Four cases were excluded because a breach in the described protocol for application of the N + 7 rule was identified at the time of the operation. Of the remaining 56 cases, 28 (50%) were fixed with an interference screw on the tibia, whereas 28 (50%) required fixation with sutures tied over a post. The 28 cases not amenable to interference screw fixation included 17 cases in which the tibial tunel was too long and 11 cases in which the tunnnel was too short. It appears that the applicability of the N + 7 rule to an individual surgeon's practice may be altered by small variations in operative technique.