Reducing Narcotic Usage With 0.5% Bupivacaine Periarticular Injections in Total Knee Arthroplasty.

BACKGROUND: Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB. METHODS: This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI). RESULTS: In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003). CONCLUSION: Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high.

Anatomic and Patient Risk Factors for Postoperative Periprosthetic Hip Fractures: A Case-Control Study.

BACKGROUND: Periprosthetic fracture remains a major source of reoperation following total hip arthroplasty (THA). Within 90 days of surgery, fractures may occur spontaneously or with minor injury and are therefore more likely related to patient factors including anatomic variation. METHODS: From 2008 to 2018, 16,254 primary THAs were performed at our institution; of those, 48 were revised for periprosthetic fracture within 90 days of surgery. A control group of 193 patients undergoing THA for hip osteoarthritis (OA) was randomly selected from the source population. We excluded patients with genetic bone disease and THA performed for hip fracture. We used logistic regression to analyze associations between patient factors (demographics, anatomical factors, comorbidities, surgical technique, and implants) and odds of 90-day periprosthetic fracture. RESULTS: Increased age was significantly associated with fracture (P = .002), as was female gender (P = .046). After adjusting for age and gender, absence of contralateral OA was associated with increased odds of fracture relative to patients with contralateral OA (odds ratio [OR] 3.85, 95% confidence interval [CI] 1.60-9.29), as was having a contralateral THA in place (OR 3.70, 95% CI 1.59-8.60). The neck-shaft angle, femoral offset, and the Dorr classification were not associated with increased odds of fracture. Additionally, the distance from the tip of the trochanter to the top of the femoral head was associated with increased odds of fracture per half centimeter (OR 1.48, 95% CI 1.14-1.93). CONCLUSION: Risk of early postoperative periprosthetic fracture following THA is increased with age, female gender, and increasing distance from the greater trochanter to the top of the femoral head; and decreased in the setting of contralateral hip OA. The trochanter-head distance correlation with periprosthetic hip fracture indicates that the preoperative anatomy may influence PPF, particularly regarding how that anatomy is reconstructed.

Pectoralis Major Tendon Insertion Anatomy and Description of a Novel Anatomic Reference.

Pectoralis major rupture is an uncommon injury often treated surgically, requiring anatomic knowledge of the tendon insertion. This study defines the pectoralis major tendon insertion footprint and a novel anatomic relationship. Twelve cadaver shoulders were evaluated andmeasured using a standard surgical ruler to demonstrate the normal anatomic footprint. Measurements were taken from the anterior medial margin of the articular surface of the humeral head to the superior margin of the pectoralis major insertion and its relation to the latissimus dorsi tendon insertion. The average length and width of the pectoralis major insertion were 73.3 ± 10.0 mm and 3.3 ± 0.54 mm, respectively, consistent with previous publications. On average, the superior margin of the pectoralis tendon was within 1 mm of the latissimus dorsi insertion and 41.2 ± 9.27 mm from the articular margin. These points form a new anatomic reference of the latissimus dorsi, providing an intraoperative reference point when performing pectoralis major muscle tendon repair. (Journal of Surgical Orthopaedic Advances 27(1):39-41, 2018).

Postoperative Outcome of the Modified Broström Procedure in the Active Duty Military Population: A Retrospective Cohort Study.

Ankle sprains are common injuries and typically treated conservatively. Chronic ankle instability, however, can require surgery when nonoperative measures fail. We evaluated the clinical outcomes of an active duty population in a retrospective study of patients who had undergone a modified Broström procedure at our facility from January 2010 through April 2014 by a single surgeon. The electronic medical records and Army E-profile database were reviewed to determine whether the patients had returned to active duty and whether they had any permanent postoperative lower extremity activity restrictions. A total of 127 patients met the inclusion criteria and had undergone the modified Broström procedure during the study period; 34 (26.8%) separated from the military postoperatively. Of these 34 patients, 23 (18.1%) were unfit for reasons related to their ankle and 11 (8.7%) required military separation for reasons unrelated to their ankle. Thus, 93 patients (73.2%) were able to remain on active duty after undergoing the Broström procedure. Of the 93 patients able to remain on active duty, 38 (40.9%) required activity modifications and 55 (59.1%) were able to return to full duty. Chronic ankle instability in active duty patients can be severely limiting. The modified Broström procedure can provide significant improvement in symptoms and allow patients to remain on active duty. In our high-demand population, ~73% of patients were able to remain on active duty after their injury and subsequent surgery, 60% of whom returned to their previous level of duty without any physical restrictions.

Correlation of Patient-Reported Preoperative Narcotic Use and Postoperative Requirements in Total Joint Arthroplasty.

Preoperative narcotic use is associated with diminished outcomes and increased complications in patients undergoing primary total joint arthroplasty (TJA). The goal of this study was to compare self-reported and state database identified preoperative narcotic use and correlate it with perioperative narcotic requirements in patients undergoing primary arthroplasty. A total of 788 patients undergoing unilateral TJA from a single institution were examined using self-reported preoperative narcotic use questionnaires and were verified using the Massachusetts Prescriber Awareness Tool (MassPAT). Demographic data, perioperative morphine milligram equivalents, and postdischarge refills were recorded and analyzed. Of the total population, 16.4% of patients undergoing TJA had verified MassPAT narcotics prescriptions preoperatively. Of these patients, 55% accurately reported use to their surgeon. Patients with verified MassPAT narcotic prescriptions required more morphine milligram equivalents than patients without MassPAT prescriptions, regardless of their preoperative self-report at all time points in the study. Patients who accurately reported use required more narcotics than those who did not. Patients with MassPAT prescriptions required more postdischarge refills than patients without MassPAT prescriptions. These data suggest that state-run narcotics databases may be more useful than self-reports for identifying which patients may require more opioids both immediately postoperatively and after hospital discharge. [Orthopedics. 2024;47(1):34-39.].

Comparison of complication rates of intramedullary pin fixation versus plating of midshaft clavicle fractures in an active duty military population.

Military service members have increased requirements of shoulder weight bearing to perform duties. Operative intervention has increased for treatment of displaced middle one-third clavicle fractures. Complications of operatively treated clavicle fixation have not been extensively studied. A retrospective, longitudinal cohort chart evaluation was conducted of all active duty members undergoing fixation of middle one-third clavicle fractures, for complications between intramedullary pin fixation and plate constructs. This review found 62 patients meeting inclusion criteria. Thirty-three patients underwent intramedullary pin fixation with Hagie pins and 31 patients underwent precontoured superior clavicle plate fixation of their middle one-third clavicle fractures. Complications included wound infection, skin and/or soft tissue irritation, and need for unplanned hardware removal. The overall complication rate was 31% in the plate fixation group versus 9% in the intramedullary pin group (p = .024). All patients achieved fracture union with return to duty; however, increased overall complications were seen in the plate fixation group.

Secondary Surgery Rates After Primary Fusion for Adolescent Idiopathic Scoliosis.

Instrumented spinal fusion is the gold standard treatment for surgical magnitude adolescent idiopathic scoliosis (AIS), with the goal being stable fusion without the need for additional procedures. The purpose of this study was to define the surgical return rates of AIS at a single center with respect to various instrumentation constructs used during initial spinal fusion. A retrospective chart review was performed of all patients with AIS who underwent instrumented fusion with a minimum of 2-year follow-up. Demographic information, implant type, and surgical approach for the primary surgery and all subsequent secondary operations were recorded. Four hundred eleven patients who underwent instrumented fusion for AIS during the study period met inclusion criteria. Sixty-six secondary operations were performed in 50 patients (12.2%). Symptomatic hardware, pseudarthrosis, and infection were the most common indications for secondary surgery. Posterior pedicle screw constructs had a lower secondary surgery rate (5.8%) compared with hybrid and combined fusions (P<.05). The all hook, hybrid, anterior only, and combined fusions had secondary surgery rates of 13.0%, 18.5%, 10.0%, and 20.8%, respectively, which were not statistically different. When specifically comparing pedicle screw with hook constructs, there was a statistically lower pseudarthrosis rate (P=.03) favoring pedicle screw instrumentation. Patients undergoing instrumented fusion for AIS are at some risk for subsequent surgery. To lessen that risk, pedicle screw constructs should be considered, as they have shown an overall lower secondary surgery rate and in particular a lower rate of pseudarthrosis. [Orthopedics. 2019; 42(4):235-239.].

Infection Rate of Intramedullary Nailing in Closed Fractures of the Femoral Diaphysis After Temporizing External Fixation in an Austere Environment.

OBJECTIVES: To determine the infection rate of intramedullary (IM) nailing of closed diaphyseal femur fractures after temporary stabilization with external fixation in an austere combat environment. DESIGN: Retrospective case series. SETTING: Iraq and Afghanistan Theater and Military Medical Treatment Centers in the United States and Landstuhl, Germany. PATIENTS: Military personnel who underwent temporizing external fixation of a closed diaphyseal femur fracture (OTA 32) with later conversion to an IM nail between 2003 and 2012. INTERVENTION: Patients were identified from the Joint Theater Trauma Registry and Department of Defense electronic medical record, and a retrospective review was performed. MAIN OUTCOME MEASUREMENTS: Variables measured included age, gender, mechanism of injury, Injury Severity Score, associated injuries (to include thoracic and abdominal injuries), base deficit, history of massive transfusion, date of injury, date and place of external and IM fixations, time to conversion procedure, report of superficial or deep infection, report of fracture union, and date of last follow-up. RESULTS: One hundred twenty-two patients, mean age 25 (18-43) years, sustained 125 closed femoral diaphyseal fractures from May 2003 to July 2012. External fixation was performed at a mean of 0.2 days (median of the day of injury) and a range of 0-3 days. Mean time to IM nail conversion procedure was 6.9 (1-20) days. Infection rate was 2.5%, with a P of 0.188. Average follow-up was 41.4 (12-119) months. CONCLUSIONS: Acceptable low infection rates can be achieved after IM nailing of closed diaphyseal femur fractures treated with initial external fixation in an austere combat environment. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pseudarthrosis of the clavicle.

A 21-year-old active duty soldier presented with right shoulder pain and prominence over his right clavicle, with no history of trauma. He recalled that the deformity had been present for a long time, but only recently became painful. The onset of shoulder pain coincided with the beginning of his military service and the requirement to wear over-the-shoulder equipment such as back packs and load-bearing equipment. Physical examination revealed a prominence over the right midshaft clavicle with tenderness to palpation, full active range of motion of the shoulder, and that he was neurovascularly intact.