No abstract

Introduction: Periarticular multimodal analgesic injection associates with less postoperative (post-op) pain after total knee arthroplasty (TKA) with less opioid consumption. The combination of additives and dosage are various and controversial. Evidence of ketorolac compared to triamcinolone as an additive is limited in terms of efficacy and safety. Materials and Methods: Fifty-six patients with unilateral TKA were randomized to receive either 60mg ketorolac or 80mg triamcinolone acetonide as cocktail additives in periarticular injection. Significant threshold was considered if the adjusted mean difference of morphine consumption was greater than 3mg at any timepoint. The primary outcomes were morphine consumptions at immediate post-op, 24 hour (h), 48h, and 72h post-op. Pain visual analogue scale (VAS), knee range of motion, straight leg raising ability, and adverse events were secondary outcomes. Results: Adjusted mean differences (ketorolac-triamcinolone) in morphine consumption were -0.4, 2.5, 2.6, and 2.3mg at given timepoints without significance. No difference observed in pain VAS at rest and during motion, post-op knee extension, and straight leg raising ability. However, post-op knee flexion was significantly higher in triamcinolone group at any timepoints (mean differences 10.3, 10.6, and 9.7, respectively, p<0.05). Conclusions: Periarticular analgesic injection containing 60mg ketorolac provided similar analgesic efficacy and early functional recovery compared with 80mg triamcinolone acetonide. However, triamcinolone may benefit over ketorolac in early post-op knee flexion.

Update This article was updated on April 10, 2024, because of a previous error. On page 1304, the term “protein” that appeared incorrectly three times in the text that had read as “Their studies did reveal that metabolites from the protein pump inhibitor ingestion may directly and indirectly influence bone density through plasma metabolites involved in the sex hormone pathway. This article plus others have broadened the possible altered pathways related to protein pump inhibitor use. Regardless, these commonly used agents will compromise bone health. Clinicians should be alerted to this possibility when protein pump inhibitors are ingested.,” has now been replaced with the term “proton” so that the text now reads as “Their studies did reveal that metabolites from the proton pump inhibitor ingestion may directly and indirectly influence bone density through plasma metabolites involved in the sex hormone pathway. This article plus others have broadened the possible altered pathways related to proton pump inhibitor use. Regardless, these commonly used agents will compromise bone health. Clinicians should be alerted to this possibility when proton pump inhibitors are ingested.”

Background: Intra-articular injection in the dry knee joint is technically challenging particularly for the beginners. The aim of this study was to investigate the possible use of the vibration sensor to detect if the needle tip was at the knee intra-articular position by characterizing the frequency component of the vibration signal during empty syringe air injection.Methods: Two milliliters of air were injected supero-laterally at extra- and intra-articular positions of a cadaveric knee joint, using needles of size 18, 21 and 24 gauge. Ultrasonography was used to confirm the positions of needle tip. A piezoelectric accelerometer was mounted medially on the knee joint to collect the vibration signals which were analyzed to characterize the frequency components of the signals during injections. Results: The vibration frequency band power in the range of 500-1,500 Hertz was visually observed to potentially localize the needle tip placement during air injection whether they were at the knee extra-articular or intra-articular positions, as demonstrated by the higher band power (over -40 decibel or dB) for all the needle sizes. The differences of frequency band power between extra- and intra-articular positions were 18.1 dB, 26.4 dB and 39.2 dB for the needle size 18, 21 and 24 gauge respectively. The most obvious difference was found in the smallest needle diameter.Conclusions: A vibration sensor approach was preliminarily proved to distinguish the intra-articular from extra-articular needle placement in the knee joint. This study demonstrated a possible alternative electronic device implementation of this technique to detect the intra-articular knee injection.

We recently read the published article in your Journal [1], and it is an interesting article. This study is a double-blinded, randomized, noninferiority study to evaluate the efficacy of ketorolac and triamcinolone in intraarticular injections in the hip and knee. Although we appreciate their efforts, we have some concerning issues regarding the methodology of noninferiority trials in this study. We would like to ask about three issues regarding conducting noninferiority trials. First, the authors have hypothesized that clinical improvement, as evidenced by Patient-Reported Outcome Measures (PROMs), would be comparable in terms of both efficacy and duration between the two groups. The authors have not even stated the amount of magnitude of the comparable (PROMs in the ketorolac group are not worse than PROMs in the triamcinolone group) PROMs in both groups, which is known as the noninferiority margin, and also, the appropriate estimation of type I and II errors to demonstrate the noninferiority results of the treatments have not been stated [2]. Second, the authors have not mentioned how to calculate the study sample size based on the noninferiority hypotheses. Finally, we would like to point out a format issue in reporting a noninferiority trial. According to the 2010 CONSORT statement, the interpretations of noninferiority results should address the relationship between the confident interval of the effect estimates and the noninferiority margins with appropriate figures [3].