Search

Background: The perioperative inflammatory response as measured by elevated levels of interleukin-6 (IL-6) has been linked to acute respiratory distress syndrome, postoperative confusion, and fever. Because of the extent of surgery,patients undergoing bilateral total knee arthroplasty may be at high risk of complications. We had found a significant decrease in IL-6 in patients having bilateral total knee replacement who received two doses of 100 mg of hydrocortisone eight hours apart; however, by twenty-four hours, IL-6 levels were equal to those in the group that received a placebo. In the present study, we investigated whether the administration of three doses would reduce IL-6 levels at twenty-four hours and affect other outcomes such as desmosine level, a marker of lung injury.Methods: After institutional review board approval, a total of thirty-four patients (seventeen patients and seventeen control subjects) were enrolled in this double-blind, randomized, placebo-controlled study. Three doses of intravenous hydrocortisone (100 mg) or placebo were given eight hours apart. Urinary desmosine levels were obtained at baseline and at one and three days postoperatively. The level of IL-6 was measured at baseline and at six, ten, twenty-four, and forty-eight hours postoperatively. Pain scores, presence of fever, and functional outcomes were recorded.Results: The level of IL-6 increased in both groups, but was significantly higher in the control group, peaking at twenty-four hours (mean and standard deviation, 623.74 ± 610.35 pg/mL versus 148.13 ± 119.35 pg/mL; p = 0.006). Urinary desmosine levels significantly increased by twenty-four hours in the control group, but remained unchanged in the study group (134.75 ± 67.88 pmol/mg and 79.45 ± 46.30 pmol/mg, respectively; p = 0.006). Pain scores at twenty-four hours were significantly lower in the study group (1.4 ± 0.9 versus 2.4 ± 1.2; p = 0.01) as was the presence of fever (11.8%versus 47.1%; p = 0.03). Range of motion at the knee was significantly greater in the study group (81.6 ± 11.6 versus 70.6 ± 14.0 in the right knee [p = 0.02] and 81.4 ± 11.3 versus 73.4 ± 9.4 in the left knee [p = 0.03]).Conclusions: Hydrocortisone (100 mg) given over three doses, each eight hours apart, decreased and maintained a lower degree of inflammation with bilateral total knee replacement as measured by IL-6 level. Corticosteroids decreased the prevalence of fever, lowered visual analog pain scores, and improved knee motion. The significantly lower values of desmosine in the study group suggest that this treatment may be protective against lung injury. [ABSTRACT FROM AUTHOR]

In 1994, Fischer et al. established the preoperative clinic for the perioperative services at Stanford University Medical Center. By lowering the risk of cancellation and reducing morbidity and mortality against the push to move surgeries to an outpatient, basis, they demonstrated a return on investment. In the 2000s, Aronson et al. designed the prehabilitation clinics at Duke University with the notion that the preoperative process should not only ensure that patients were appropriately risk-stratified, but also clinically optimized before surgery. With a trend towards ambulatory procedures due to current reimbursement structures, hospital administrators should be searching for potential avenues to bolster sagging profits. In this narrative review, we argue that the perioperative services needs to extend beyond the hospital into the postoperative period., Competing Interests: Declaration of competing interest Kethy M. Jules-Elysee declares that she has no conflict of interest. Alana E. Sigmund owns stock in Bristo-Meyers-Squibb and Pfizer; she declares no conflict of interest. Mitchell H. Tsai declares that he has no conflict of interest. Jeff W. Simmons declares that he has no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Optimal analgesic protocols for total knee arthroplasty (TKA) patients remain controversial. Multimodal analgesia is advocated, often including peripheral nerve blocks and/or periarticular injections (PAIs). If 2 blocks (adductor canal block [ACB] plus infiltration between the popliteal artery and capsule of the knee [IPACK]) are used, also performing PAI may not be necessary. This noninferiority trial hypothesized that TKA patients with ACB + IPACK + saline PAI (sham infiltration) would have pain scores that were no worse than those of patients with ACB + IPACK + active PAI with local anesthetic., Methods: A multimodal analgesic protocol of spinal anesthesia, ACB and IPACK blocks, intraoperative ketamine and ketorolac, postoperative ketorolac followed by meloxicam, acetaminophen, duloxetine, and oral opioids was used. Patients undergoing primary unilateral TKA were randomized to receive either active PAI or control PAI. The active PAI included a deep injection, performed before cementation, of bupivacaine 0.25% with epinephrine, 30 mL; morphine; methylprednisolone; cefazolin; with normal saline to bring total volume to 64 mL. A superficial injection of 20 mL bupivacaine, 0.25%, was administered before closure. Control injections were normal saline injected with the same injection technique and volumes. The primary outcome was numeric rating scale pain with ambulation on postoperative day 1. A noninferiority margin of 1.0 was used., Results: Ninety-four patients were randomized. NRS pain with ambulation at POD1 in the ACB + IPACK + saline PAI group was not found to be noninferior to that of the ACB + IPACK + active PAI group (difference = 0.3, 95% confidence interval [CI], [-0.9 to 1.5], P = .120). Pain scores at rest did not differ significantly among groups. No significant difference was observed in opioid consumption between groups. Cumulative oral morphine equivalents through postoperative day 2 were 89 ± 40 mg (mean ± standard deviation), saline PAI, vs 73 ± 52, active PAI, P = .1. No significant differences were observed for worst pain, fraction of time in severe pain, pain interference, side-effects (nausea, drowsiness, itching, dizziness), quality of recovery, satisfaction, length of stay, chronic pain, and orthopedic outcomes., Conclusions: For TKA patients given a comprehensive analgesic protocol, use of saline PAI did not demonstrate noninferiority compared to active PAI. Neither the primary nor any secondary outcomes demonstrated superiority for active PAI, however. As we cannot claim either technique to be better or worse, there remains flexibility for use of either technique., Competing Interests: Conflicts of Interest: See Disclosures at the end of the article., (Copyright © 2024 International Anesthesia Research Society.)

Introduction: The direct anterior approach (DAA) for total hip arthroplasty (THA) is considered less invasive than the posterolateral approach (PLA), possibly leading to earlier mobilization, faster recovery, and lower levels of thrombogenic markers. The purpose of the current study was to prospectively compare readiness for discharge, rehabilitation milestones, markers of thrombosis and inflammation at 6 weeks postoperatively between DAA and PLA., Methods: A total of 40 patients (20 anterior and 20 posterolateral) were prospectively enrolled. Readiness for discharge, length of stay (LOS), and related outcomes were additionally documented. Blood was drawn at baseline, wound closure, 5-h post-closure, and 24-h post-closure for assays of interleukin-6 (IL-6), PAP (plasmin anti-plasmin), a marker of fibrinolysis, and PF1.2 (Prothrombin fragment 1.2), a marker of thrombin generation., Results: Compared to the PLA group, the DAA group was ready for discharge a mean 13 h earlier (p = 0.03), while rehabilitation milestones were met a mean 10 h earlier (p = 0.04), and LOS was 13 h shorter (p = 0.02) on average. Pain scores at all study timepoints and patient satisfaction at 6 weeks were similar (p > 0.05). At 24 h postoperatively, PAP levels were 537.53 ± 94.1 µg/L vs. 464.39 ± 114.6 µg/L (p = 0.05), and Il-6 levels were 40.94 ± 26.1 pg/mL vs. 60.51 ± 33.0 pg/mL (p = 0.03), in DAA vs. PLA, respectively., Conclusions: In the immediate postoperative period, DAA patients were ready for discharge before PLA patients. DAA patients had shorter LOS, a lower inflammatory response, and higher systemic markers of fibrinolysis. However, these differences may not be clinically significant. Future studies with larger study populations are warranted to confirm the validity and significance of these findings., Level of Evidence: Level II, Therapeutic Study., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: With an aging population, orthopedics has become one of the largest and fastest growing surgical fields. However, data on the use of critical care services (CCS) in patients undergoing orthopedic procedures remain sparse. Purpose: We sought to elucidate the prevalence and characteristics of patients requiring CCS and intermediate levels of care after orthopedic surgeries at a high-volume orthopedic medical center. Methods: We retrospectively reviewed inpatient electronic medical record data (2016-2020) at a high-volume orthopedic hospital. Patients who required CCS and intermediate levels of care, including step-down unit (SDU) and telemetry services, were identified. We described characteristics related to patients, procedures, and outcomes, including type of advanced services required and surgery type. Results: Of the 50,387 patients who underwent orthopedic inpatient surgery, 1.6% required CCS and 21.6% were admitted to an SDU. Additionally, 482 (1.0%) patients required postoperative mechanical ventilation and 3602 (7.1%) patients required continuous positive airway pressure therapy. Spine surgery patients were the most likely to require any form of advanced care (45.7%). Conclusions: This retrospective review found that approximately one-fourth of orthopedic surgery patients were admitted to units that provided critical and intermediate levels of care. These results may prove useful to hospitals in estimating needs and allocating resources for advanced and critical care services after orthopedic surgery., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Haoyan Zhong, MPA, Sean Garvi, MD, Jashvant Poeran, MD, PhD, Jiabin Liu, MD, PhD, Meghan Kirksey, MD, PhD, Lauren A. Wilson, MPH, Danya DeMeo, BS, Elaine Yang, MD, Genewoo Hong, MD, JD, Kethy M. Jules-Elysee, MD, and Jemiel Nejim, MD, declare they have nothing to disclose. Stavros G. Memtsoudis, MD, PhD, MBA, FCCP, reports relationships with Parvizi Surgical Innovations, LLC., Teikoku Pharma, Inc., and HATH. He is the owner of SGM Consulting, LLC, and co-owner of Centauros Healthcare Analytics and Consulting, LLC., (© The Author(s) 2021.)

Background: Duloxetine, a serotonin-norepinephrine dual reuptake inhibitor, may improve analgesia after total knee arthroplasty (TKA). Previous studies had one primary outcome, did not consistently use multimodal analgesia, and used patient-controlled analgesia devices, potentially delaying discharge. We investigated whether duloxetine would reduce opioid consumption or pain with ambulation., Methods: A total of 160 patients received 60 mg duloxetine or placebo daily, starting from the day of surgery and continuing 14 days postoperatively. Patients received neuraxial anesthesia, peripheral nerve blocks, acetaminophen, nonsteroidal anti-inflammatory drugs, and oral opioids as needed. The dual primary outcomes were Numeric Rating Scale (NRS) scores with movement on postoperative days 1, 2, and 14, and cumulative opioid consumption surgery through postoperative day 14., Results: Duloxetine was noninferior to placebo for both primary outcomes and was superior to placebo for opioid consumption. Opioid consumption (mean ± SD) was 288 ± 226 mg OME [94, 385] vs 432 ± 374 [210, 540] (duloxetine vs placebo) P = .0039. Pain scores on POD14 were 4.2 ± 2.0 vs 4.8 ± 2.2 (duloxetine vs placebo) P = .018. Median satisfaction with pain management was 10 (8, 10) and 8 (7, 10) (duloxetine vs placebo) P = .046. Duloxetine reduced interference by pain with walking, normal work, and sleep., Conclusion: The 29% reduction in opioid use corresponds to 17 fewer pills of oxycodone, 5 mg, and was achieved without increasing pain scores. Considering the ongoing opioid epidemic, duloxetine can be used to reduce opioid usage after knee arthroplasty in selected patients that can be appropriately monitored for potential side effects of the medication., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The development of hyponatremia after total joint arthroplasty (TJA) may lead to several adverse events and is associated with prolonged inpatient length of stay as well as increased hospital costs. The purpose of this study was to develop and internally validate machine learning algorithms for predicting hyponatremia after TJA., Methods: A consecutive cohort of 30,703 TJA patients from an institutional registry at a large, tertiary academic hospital were included. A total of 19 potential predictor variables were collected. Hyponatremia was defined as a serum sodium concentration of <135 mEq/L. Five machine learning algorithms were developed using a training set and internally validated using an independent testing set. Algorithm performance was evaluated through discrimination, calibration, decision-curve analysis, and Brier score., Results: The charts of 30,703 patients undergoing TJA were reviewed. Of those patients, 5,480 (17.8%) developed hyponatremia postoperatively. A combination of 6 variables were demonstrated to optimize algorithm prediction: preoperative serum sodium concentration, age, intraoperative blood loss, procedure time, body mass index (BMI), and American Society of Anesthesiologists (ASA) score. Threshold values that were associated with greater hyponatremia risk were a preoperative serum sodium concentration of ≤138 mEq/L, an age of ≥73 years, an ASA score of >2, intraoperative blood loss of >407 mL, a BMI of ≤26 kg/m2, and a procedure time of >111 minutes. The stochastic gradient boosting (SGB) algorithm demonstrated the best performance (c-statistic: 0.75, calibration intercept: -0.02, calibration slope: 1.02, and Brier score: 0.12). This algorithm was turned into a tool that can provide real-time predictions (https://orthoapps.shinyapps.io/Hyponatremia&#95;TJA/)., Conclusions: The SGB algorithm demonstrated the best performance for predicting hyponatremia after TJA. The most important factors for predicting hyponatremia were preoperative serum sodium concentration, age, intraoperative blood loss, procedure time, BMI, and ASA score. A real-time hyponatremia risk calculator was developed, but it is imperative to perform external validation of this model prior to using this calculator in clinical practice., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G828)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: SARS-CoV-2 infection can cause serious complications beyond lung injury and respiratory failure, including sepsis, cardiovascular injury, renal failure, coagulation abnormalities, and neurologic injury. Widely used medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) have been flagged as having the potential to cause harm in the context of COVID-19. It is unknown if the benefits of NSAID use in the orthopedic population will outweigh the potential risks of increased morbidity in COVID-19 orthopedic patients., Methods: We conducted a narrative review of the use of NSAIDs in the orthopedic patient with COVID-19, focusing on the effects of NSAIDs on the inflammatory process, the role of NSAIDs in orthopedics, and the associations between NSAID use and complications of pneumonia., Results: We found that it may be appropriate to consider NSAID use in otherwise healthy orthopedic patients with COVID-19 and significant pain., Conclusions: In this context, we recommend that NSAIDs be used at the lowest effective dose for the shortest duration possible in orthopedic patients with COVID-19. However, pending further data and based on the concerns outlined in this review, we recommend avoiding NSAIDs in orthopedic patients with significant comorbidities and those who are undergoing major orthopedic surgery., Competing Interests: Conflict of InterestChristopher L. Wu, MD, Kethy M. Jules-Elysee, MD, Meghan A. Kirksey, MD, PhD, and Gregory A. Liguori, MD, declare that they have no conflict of interest., (© Hospital for Special Surgery 2020.)

Background: Tranexamic acid (TXA) is an antifibrinolytic drug. Topical administration of TXA during total knee arthroplasty (TKA) is favored for certain patients because of concerns about thrombotic complications, despite a lack of supporting literature. We compared local and systemic levels of thrombogenic markers, interleukin (IL)-6, and TXA between patients who received intravenous (IV) TXA and those who received topical TXA., Methods: Seventy-six patients scheduled for TKA were enrolled in this randomized double-blinded study. The IV group received 1.0 g of IV TXA before tourniquet inflation and again 3 hours later; a topical placebo was administered 5 minutes before final tourniquet release. The topical group received an IV placebo before tourniquet inflation and again 3 hours later; 3.0 g of TXA was administered topically 5 minutes before final tourniquet release. Peripheral and wound blood samples were collected to measure levels of plasmin-anti-plasmin (PAP, a measure of fibrinolysis), prothrombin fragment 1.2 (PF1.2, a marker of thrombin generation), IL-6, and TXA., Results: At 1 hour after tourniquet release, systemic PAP levels were comparable between the IV group (after a single dose of IV TXA) and the topical group. At 4 hours after tourniquet release, the IV group had lower systemic PAP levels than the topical group (mean and standard deviation, 1,117.8 ± 478.9 µg/L versus 1,280.7 ± 646.5 µg/L; p = 0.049), indicative of higher antifibrinolytic activity after the second dose. There was no difference in PF1.2 levels between groups, indicating that there was no increase in thrombin generation. The IV group had higher TXA levels at all time points (p < 0.001). Four hours after tourniquet release, wound blood IL-6 and TXA levels were higher than systemic levels in both groups (p < 0.001). Therapeutic systemic TXA levels (mean, 7.2 ± 7.4 mg/L) were noted in the topical group. Calculated blood loss and the length of the hospital stay were lower in the IV group (p = 0.026 and p = 0.025)., Conclusions: Given that therapeutic levels were reached with topical TXA and the lack of a major difference in the mechanism of action, coagulation, and fibrinolytic profile between topical TXA and a single dose of IV TXA, it may be a simpler protocol for institutions to adopt the use of a single dose of IV TXA when safety is a concern., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Continuous popliteal nerve block is utilized for postoperative analgesia after foot and ankle surgery. Whether only the total dose of local anesthetic or the combination of concentration and volume determine the characteristics of a continuous popliteal nerve infusion remains currently unknown. We hypothesized a reduction of the incidence of insensate extremity in patients given ropivacaine 0.4% at 4 mL/h compared to patients given ropivacaine 0.2% at 8 mL/h., Methods: Sixty-four patients scheduled for major foot and ankle surgery requiring a continuous popliteal catheter infusion for postoperative analgesia were studied. Thirty-three patients were randomized to receive a continuous popliteal nerve block with 0.2% (basal 8 mL/h) and thirty-one with 0.4% (basal 4 mL/h) ropivacaine, reaching the same total dose (16 mg/h). The primary outcome was the incidence of persistent sensory block in the distal sciatic nerve distributions in the postoperative period. Secondary outcomes were the incidence of motor block, NRS pain scores at rest in the postoperative period up to 48 hours after surgery, opioid use and related side effects, patients' satisfaction., Results: The incidence of persistent sensory block was similar in patients given 0.2% and in patients receiving 0.4% ropivacaine. The incidence of motor block, postoperative pain scores at rest, use of oral opioids, side effects and patients' satisfaction with the quality of recovery were also similar in both groups., Conclusions: Our results suggest that local anesthetic total dose is the primary determinant of continuous popliteal perineural infusion effects.

Mycobacterium avium complex is a rare cause of musculoskeletal infection, usually occurring in patients with compromised immune systems. Obtaining the diagnosis requires a high index of suspicion, and treatment can be delayed because of difficulty with isolating the organism. Treatment involves prolonged, targeted combination antibiotic therapy, and it is unclear whether eradication of the infection can occur in the presence of a foreign body, such as antibiotic spacers. The authors report a case of M avium infection presenting as presumed osteonecrosis of the femoral head in a young woman with systemic lupus erythematosus. She presented with collapse of her femoral head coinciding with several months of progressive, debilitating hip pain. She had mild fevers during that time, but results from multiple infectious workups, including hip aspiration, were negative. Purulent fluid was found in the operating room, but diagnosis was delayed for 5 weeks while waiting for cultures. The patient required 3 subsequent operations, eventually being left with a resection arthroplasty. Pertinent issues concerning diagnosis, therapy, and treatment challenges in M avium infections of the musculoskeletal system are discussed in this case report. [Orthopedics. 2017; 40(3):e549-e552.]., (Copyright 2017, SLACK Incorporated.)

Background: Duloxetine is effective for chronic musculoskeletal and neuropathic pain, but there are insufficient data to recommend the use of antidepressants for postoperative pain. The authors hypothesized that administration of duloxetine for 15 days would reduce pain with ambulation at 2 weeks after total knee arthroplasty., Methods: In this triple-blinded, randomized, placebo-controlled trial, patients received either duloxetine or placebo for 15 days, starting from the day of surgery. Patients also received a comprehensive multimodal analgesic regimen including neuraxial anesthesia, epidural analgesia, an adductor canal block, meloxicam, and oxycodone/acetaminophen as needed. The primary outcome was the pain score (0 to 10 numeric rating scale) with ambulation on postoperative day 14., Results: One hundred six patients were randomized and analyzed. On day 14, duloxetine had no effect on pain with ambulation; mean pain was 3.8 (SD, 2.3) for placebo versus 3.5 (SD, 2.1) for duloxetine (difference in means [95% CI], 0.4 [-0.5 to 1.2]; P = 0.386). Symptoms potentially attributable to duloxetine discontinuation at study drug completion (nausea, anxiety) occurred among nine patients (duloxetine) and five patients (placebo); this was not statistically significant (P = 0.247). Statistically significant secondary outcomes included opioid consumption (difference in mean milligram oral morphine equivalents [95% CI], 8.7 [3.3 to 14.1], P = 0.002 by generalized estimating equation) over the postoperative period and nausea on day 1 (P = 0.040). There was no difference in other side effects or in anxiety and depression scores., Conclusions: When included as a part of a multimodal analgesic regimen for knee arthroplasty, duloxetine does not reduce subacute pain with ambulation.

Background: Pregabalin may reduce postoperative pain and opioid use. Higher doses may be more effective, but may cause sedation and confusion. This prospective, randomized, blinded, placebo-controlled study tested the hypothesis that pregabalin reduces pain at 2 weeks after total knee arthroplasty, but increases drowsiness and confusion., Methods: Patients (30 per group) received capsules containing pregabalin (0, 50, 100, or 150 mg); two capsules before surgery, one capsule twice a day until postoperative day (POD) 14, one on POD15, and one on POD16. Multimodal analgesia included femoral nerve block, epidural analgesia, oxycodone-paracetamol, and meloxicam. The primary outcome was pain with flexion (POD14)., Results: Pregabalin did not reduce pain at rest, with ambulation, or with flexion at 2 weeks (P=0.69, 0.23, and 0.90, respectively). Pregabalin increased POD1 drowsiness (34.5, 37.9, 55.2, and 58.6% in the 0, 50, 100, and 150 mg arms, respectively; P=0.030), but did not increase confusion (0, 3.5, 0, and 3.5%, respectively; P=0.75). Pregabalin had no effect on acute or chronic pain, opioid consumption, or analgesic side-effects. Pregabalin reduced POD14 patient satisfaction [1-10 scale, median (first quartile, third quartile): 9 (8, 10), 8 (7, 10), 8 (5, 9), and 8 (6, 9.3), respectively; P=0.023). Protocol compliance was 63% by POD14 (50.0, 70.0, 76.7, and 56.7% compliance, respectively), with no effect of dose on compliance. Per-protocol analysis of compliant patients showed no effect of pregabalin on pain scores., Conclusions: Pregabalin had no beneficial effects, but increased sedation and decreased patient satisfaction. This study does not support routine perioperative pregabalin for total knee arthroplasty patients., Clinical Trial Registration: ClinicalTrials.gov: http://www.clinicaltrials.gov/ct2/show/study/NCT01333956., (© The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background and Objectives: Sciatic nerve block provides analgesia after foot and ankle surgery, but block duration may be insufficient. We hypothesized that perineural dexamethasone and buprenorphine would reduce pain scores at 24 hours., Methods: Ninety patients received ultrasound-guided sciatic (25 mL 0.25% bupivacaine) and adductor canal (10 mL 0.25% bupivacaine) blockade, with random assignment into 3 groups (30 patients per group): control blocks + intravenous (IV) dexamethasone (4 mg) (control); control blocks + IV buprenorphine (150 μg) + IV dexamethasone (IV buprenorphine); and nerve blocks containing buprenorphine + dexamethasone (perineural). Patients received mepivacaine neuraxial anesthesia and postoperative oxycodone/acetaminophen, meloxicam, pregabalin, and ondansetron. Patients and assessors were blinded to group assignment. The primary outcome was pain with movement at 24 hours., Results: There was no difference in pain with movement at 24 hours (median score, 0). However, the perineural group had longer block duration versus control (45.6 vs 30.0 hours). Perineural patients had lower scores for "worst pain" versus control (median, 0 vs 2). Both IV buprenorphine and perineural groups were less likely to use opioids on the day after surgery versus control (28.6%, 28.6%, and 60.7%, respectively). Nausea after IV buprenorphine (but not perineural buprenorphine) was severe, frequent, and bothersome., Conclusions: Pain scores were very low at 24 hours after surgery in the context of multimodal analgesia and were not improved by additives. However, perineural buprenorphine and dexamethasone prolonged block duration, reduced the worst pain experienced, and reduced opioid use. Intravenous buprenorphine caused troubling nausea and vomiting. Future research is needed to confirm and extend these observations.

Background: The optimal postoperative analgesia after primary total hip arthroplasty remains in question. This randomized, double-blind, placebo-controlled study compared the use of patient-controlled epidural analgesia (PCEA) with use of a multimodal pain regimen including periarticular injection (PAI). We hypothesized that PAI would lead to earlier readiness for discharge, decreased opioid consumption, and lower pain scores., Methods: Forty-one patients received PAI, and forty-three patients received PCEA. Preoperatively, both groups were administered dexamethasone (6 mg, orally). The PAI group received a clonidine patch and sustained-release oxycodone (10 mg), while the PCEA group had placebo. Both groups received combined spinal-epidural anesthesia and used an epidural pain pump postoperatively; the PAI group had normal saline solution, while the PCEA group had bupivacaine and hydromorphone. The primary outcome, readiness for discharge, required the discontinuation of the epidural, a pain score of <4 (numeric rating scale) without parenteral narcotics, normal eating, minimal nausea, urination without a catheter, a dry surgical wound, no acute medical problems, and the ability to independently transfer and walk 12.2 m (40 ft)., Results: The mean time to readiness for discharge (and standard deviation) was 2.4 ± 0.7 days (PAI) compared with 2.3 ± 0.8 days (PCEA) (p = 0.86). The mean length of stay was 3.0 ± 0.8 days (PAI) compared with 3.1 ± 0.7 days (PCEA) (p = 0.46). A significant mean difference in pain score of 0.74 with ambulation (p = 0.01; 95% confidence interval [CI], 0.18 to 1.31) and 0.80 during physical therapy (p = 0.03; 95% CI, 0.09 to 1.51) favored the PCEA group. The mean opioid consumption (oral morphine equivalents in milligrams) was significantly higher in the PAI group on postoperative day 0 (43 ± 21 compared with 28 ± 23; p = 0.002) and postoperative days 0 through 2 (136 ± 59 compared with 90 ± 79; p = 0.004). Opioid-Related Symptom Distress Scale (ORSDS) composite scores for severity and bothersomeness as well as scores for nausea, vomiting, and itchiness were significantly higher in the PCEA group (p < 0.05). Quality of Recovery-40 scores and patient satisfaction were similar., Conclusions: PAI did not decrease the time to discharge and was associated with higher pain scores and greater opioid consumption but lower ORSDS scores compared with PCEA. The choice for analgesic regimen may depend on a particular patient's threshold for pain and the potential side effects., (Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.)

Background and Objectives: Pregabalin is often used as a perioperative analgesic adjunct; some studies show benefit, but others do not. Adverse effects, such as confusion and sedation, have been attributed to perioperative use of pregabalin. We tested the hypothesis that pregabalin, when used as part of a multimodal analgesic regimen, reduces the duration of moderate to severe pain in the first 24 hrs following foot or ankle surgery. Secondary outcomes included measures of opioid and pregabalin adverse effects., Methods: Sixty patients scheduled for hospital admission after foot or ankle surgery entered this randomized, double-blind, placebo-controlled trial. Patients received a neuraxial anesthetic, a popliteal fossa sciatic nerve block using 30 mL 0.375% bupivacaine with clonidine 100 µg and epinephrine, a saphenous nerve block, postoperative hydromorphone intravenous patient-controlled analgesia, and oral analgesics (oxycodone/acetaminophen). Patients were randomized to receive pregabalin (100 mg preoperatively, then 50 mg every 12 hrs) or a placebo for 3 days. The primary outcome was the number of hours that patients reported moderate to severe pain., Results: Both groups reported a similar number of hours of moderate to severe pain during the first 24 hrs: 4.1 (SD, 4.1) hrs (pregabalin) versus 4.5 (SD, 3.5) hrs (placebo). Pain scores, opioid use, and adverse effects were also similar in both groups., Conclusions: No clinical benefit was obtained from perioperative administration of pregabalin (100 mg preoperative, then 50 mg every 12 hrs) as part of a multimodal postoperative analgesic regimen following foot and ankle surgery.

Background: Interleukin 6 (IL-6), a marker of inflammation, is one of the major cytokines released during joint replacement. In the orthopedic patient population, high levels have been linked to many adverse effects including acute respiratory distress syndrome, postoperative mental status changes, and fever. We looked to assess the efficacy of low-dose steroids on the postinflammatory response as measured by IL-6 in patients undergoing bilateral total knee replacement (BTKR). The role of steroids has never been evaluated before in that setting., Methods: Double-blind, randomized, placebo-controlled study of 30 patients undergoing BTKR. The study was powered in order to detect at least a 25% decrease in IL-6 from control. Hydrocortisone (100 mg) or placebo was given at 2 doses 8 hrs apart to the study and control group respectively. Clinical outcome was assessed as well., Results: Levels of IL-6 were 40% lower in the study group by 10 hrs (P = 0.0037) but were similar to the control group at 24 hrs. Greater hemodynamic stability was noted in the study group with fewer episodes of hypotension postoperatively (P = 0.031). Range of motion gained on discharge was also greatest in the study group (P = 0.049). Absence of infection and normal wound healing were noted in all patients., Conclusions: The use of hydrocortisone significantly decreased the inflammatory response in patients undergoing BTKR as measured by IL-6 production. Further studies looking at clinical implications of such findings in a larger patient population and with a longer course of steroids are warranted.

Bilateral total knee replacement (BTKR) has been associated with a higher incidence of fat embolism (FES) compared to single knee replacement. Consequently, intraoperative monitoring with a pulmonary artery catheter (PAC) has been recommended. This study compares clinical outcome in BTKR patients monitored with central venous pressure versus PAC. A retrospective chart review of 249 consecutive patients undergoing BTKR, 132 of whom had PAC insertion versus 117 who had central line insertion, over a 1-year period were included in the study. Their medical records were reviewed for co-morbidities, baseline characteristics, and type of intraoperative monitoring. Need and duration for postoperative monitoring in the postoperative care, length of hospital stay (LOHS), signs of fat embolism, development of arrhythmias, and respiratory failure were all outcome measures. A total of four patients (1.6%) had FES as per Schonfeld criteria. One of these patients died within 48 h of surgery. They all had PAC monitoring intraoperatively. Pulmonary artery pressure (PAP) remained unchanged during surgery which raises doubt as to the clinical utility and advisability of the use of PAC's in this setting. There was no statistically significant difference in cardiac or pulmonary complications, or LOHS between the two groups. Central venous pressure monitoring appears to be sufficient in patients undergoing BTKR.

Background Context: Previous reports have shown that 15% of patients who undergo sequential anterior, then posterior, surgical corrections for spinal deformities demonstrate evidence of acute lung injury. By analyzing the bronchoalveolar lavage (BAL) fluid from these patients for evidence of acute inflammation, we might gain some insight into the etiology of this acute lung injury., Purpose: To elucidate the etiology of acute lung injury after corrective surgery for adult spinal deformities., Study Design/setting: Fifteen adult patients with scoliosis scheduled for elective sequential anterior then posterior corrective (A/P) spinal deformity surgery., Patient Sample: Consecutive adult patients with scoliosis scheduled for elective corrective surgery with the author (OBA)., Outcome Measures: Patients were assessed for postoperative respiratory complications by oxygen requirements, continued mechanical ventilation, and radiological evidence of diffuse bilateral interstitial or alveolar infiltrates. An acute pulmonary inflammatory response included the presence of inflammatory cells and elevated cytokines in BAL fluid., Methods: BAL were performed after induction of anesthesia but before surgery, at the completion of surgery, and on the morning after surgery with the patient still intubated. BAL fluid was analyzed for inflammatory cells and cytokine interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) levels. Patients were assessed postoperatively for increased pulmonary vascular resistance, radiological evidence of diffuse bilateral alveolar infiltrates, and the requirement for ventilatory support beyond the first postoperative day (POD1)., Results: The cell counts of BAL fluid demonstrated significant increases in neutrophils, lymphocytes, and lipid laden macrophages (LLMAC) with surgery. The concentration of the cytokines IL-6 and TNF-alpha also increased with surgery. The elevations in BAL inflammatory cells and cytokine levels correlated positively with increased pulmonary vascular resistance and the requirement for mechanical ventilation., Conclusions: After A/P spine fusions, patients have evidence of an acute inflammatory pulmonary injury. Several etiologies exist for this finding, including blood and fluid infusions, direct trauma to the lung, a systemic inflammatory response, and the embolization of fat and bone-marrow debris. The presence of LLMAC in the lungs of these patients and the finding that the patient with the requirement for the longest ventilatory support also had the highest BAL LLMAC count, suggest that the embolization of fat and bone debris released from the spine during surgery may be at least partially responsible for the lung injury. Further studies on the mechanism of lung injury during this procedure are warranted.

Study Objective: To determine the effect of previous aerosolized pentamidine therapy on diagnosis and presentation of Pneumocystis carinii pneumonia., Design: A retrospective study., Setting: A tertiary care hospital., Patients: Fifty-two consecutive patients with P. carinii pneumonia and underlying infection with the human immunodeficiency virus (HIV) who had bronchoscopy. Twenty-one patients who were on aerosolized pentamidine therapy served as the study group. Thirty-one patients who had not received the drug served as the control group., Measurements and Main Results: The yield of bronchoalveolar lavage for P. carinii pneumonia was 62% for the study group and 100% for the control group (P less than 0.05). This lower yield was significant for the subset of patients having their first episode of P. carinii pneumonia. The yield of transbronchial biopsy was similar for both groups of patients (81% compared with 84%). The yield of bronchoscopy was not influenced by use of zidovudine. Review of lavage specimen slides suggested that there may be fewer organisms present in patients receiving aerosolized pentamidine. An atypical roentgenographic presentation of upper lobe predominant infiltrates was seen in 38% of the study patients and 7% of the control patients. In addition, pneumothoraces and cystic changes were also frequently seen in the study patients. Gallium scans, when done, were also atypical in the study group. Markers of the severity of disease, however, were similar in both groups., Conclusion: The yield of bronchoalveolar lavage for P. carinii pneumonia in HIV-infected patients is lower in patients receiving aerosolized pentamidine. Unusual roentgenographic presentations and atypical gallium scans are also found in this setting.