Minimizing Surgical Instrument Burden Increases Operating Room Efficiency and Reduces Perioperative Costs in Total Joint Arthroplasty.

BACKGROUND: Optimizing surgical trays to improve operating room efficiency and reduce costs in instrument processing is an under-appreciated strategy for cost containment. This study aimed to assess the economic impact of instrument tray optimization in total joint arthroplasty. METHODS: Thirty-five randomly selected elective primary total knee arthroplasty and total hip arthroplasty performed by 4 fellowship-trained surgeons were analyzed. Type and number of instruments used as well as timing of different steps in the sterilization process were recorded by an independent observer. Using Lean methodology, surgeons identified redundant or underutilized instruments and agreed upon the fewest number needed for each tray. Instrument utilization rates and processing time were analyzed before and after tray modifications. Annual cost savings were calculated based on a processing factor of $0.59-$11.52 per instrument. RESULTS: Only 45.5% of instruments opened for total knee arthroplasty were utilized. After optimization, 28 of 87 (32.2%) instruments were removed and the remainder could be stored in one tray. Mean set-up time decreased from 20.7 to 14.2 minutes, while 40-75 minutes were saved during the sterilization process. For total hip arthroplasty, only 36.0% of instruments were utilized. Using Lean methods, 46 of 112 (41.1%) instruments were removed and tray count was reduced to 2 trays. Mean set-up time decreased from 27.9 to 18.6 minutes, while 45-150 minutes were saved during processing. Average annual savings amounted to $281,298.05. CONCLUSION: Lean methodology can be used to eliminate redundant or underutilized instruments in total joint arthroplasty, improving surgical efficiency and generating substantial cost savings.

Intraoperative Surgeon Administered Adductor Canal Blockade Is Not Inferior to Anesthesiologist Administered Adductor Canal Blockade: A Prospective Randomized Trial.

BACKGROUND: Controlling postoperative pain and reducing opioid requirements after total knee arthroplasty remain a challenge, particularly in an era stressing rapid recovery protocols and early discharge. A single-shot adductor canal blockade (ACB) has been shown to be effective in decreasing postoperative pain. The purpose of the present study is to compare the efficacy of an anesthesiologist administered ACB and a surgeon administered intraoperative ACB. METHODS: Patients undergoing primary total knee arthroplasty were prospectively randomized to receive either an anesthesiologist administered (group 1) or surgeon administered (group 2) ACB using 15 mL of ropivacaine 0.5%. Primary outcomes were pain visual analog scale, range of motion, and opioid consumption. RESULTS: Thirty-four patients were randomized to group 1 and 29 to group 2. Opioid equivalents consumed were equal on postoperative day (POD) 0, 1, and 2. Patients in group 1 had statistically less pain on POD 0, but this did not reach clinical significance and there was no difference in pain on POD 1 or 2. Patients in group 1 had significantly increased active flexion POD 1, but there was no difference in active flexion on POD 0 or 6 weeks postop. There was no difference in patient satisfaction with pain control or short-term functional outcomes. CONCLUSION: Surgeon administered ACB is not inferior to anesthesiologist administered ACB with respect to pain, opioid consumption, range of motion, patient satisfaction, or short-term functional outcomes. Surgeon administered ACB is an effective alternative to anesthesiologist administered ACB.

Intraoperative Ketamine in Total Knee Arthroplasty Does Not Decrease Pain and Narcotic Consumption: A Prospective Randomized Controlled Trial.

BACKGROUND: Multiple studies have demonstrated that ketamine, a glutamate receptor blocker, may decrease postoperative pain in abdominal and orthopedic surgeries. However, its role with spinal anesthesia and total knee arthroplasty (TKA) remains unknown. The purpose of this study is to determine the efficacy of subanesthetic dosing of ketamine during TKA on postoperative pain and narcotic consumption. METHODS: In this prospective, randomized, double-blinded clinical trial, we enrolled 91 patients undergoing primary TKA with spinal anesthesia in a single institution from 2017 to 2018. Patients were randomized to receive intraoperative ketamine infusion at a rate of 6 mcg/kg/min for 75 minutes or a saline placebo. All patients received spinal anesthesia and otherwise identical surgical approaches, pain management, and rehabilitation protocols. Patient-reported visual analog pain scores were calculated preoperatively, postoperative days (POD) 0-7, and 2 weeks. Narcotic consumption was evaluated on POD 0 and 1. RESULTS: There was no difference in average pain between ketamine and placebo at all time points except for at PODs 1 (45 vs 56, P = .041) and 4 (39 vs 49, P = .040). For least pain experienced, patients administered with ketamine experienced a reduction in pain only at POD 4 (22 vs 35, P = .011). There was no difference in maximum pain cohorts at all time points of the study or in-hospital morphine equivalents between the 2 cohorts. CONCLUSION: As part of multimodal pain management protocol, intraoperative ketamine does not result in a clinically significant improvement in pain and narcotic consumption following TKA.

Routine Patellar Resurfacing During Total Knee Arthroplasty Is Not Cost-Effective in Patients Without Patellar Arthritis.

BACKGROUND: Currently, the decision to resurface the patella is often made irrespective of the presence of patellar arthritis. The purpose of this study is to utilize the existing literature to assess cost-utility of routinely vs selectively resurfacing the patella. METHODS: Prospective randomized studies of patella resurfacing vs non-resurfacing in total knee arthroplasty (TKA) were identified through literature review. Data from these studies represented probabilities of varied outcomes following TKA dependent upon patella resurfacing. Using previously validated utility scores from the McKnee modified Health Utilities Index, endpoint utility values were provided for each potential outcome. RESULTS: Literature review yielded a total of 14 studies with 3,562 patients receiving 3,823 TKAs, of which 1,873 (49.0%) patellae were resurfaced. Persistent postoperative anterior knee pain occurred in 20.9% vs 13.2% (P < .001) and patella reoperation was performed in 3.7% vs 1.6% (P < .001) of unresurfaced and resurfaced patella, respectively. In studies excluding those with arthritic patellae, the incidence of anterior knee pain was equivalent between groups and reoperation decreased to 1.2% vs 0% (P = .06). Patella resurfacing provided marginally improved quality-adjusted life-years (QALY) for both selective and indiscriminate patella resurfacing. When including all studies, the incremental cost per QALY was $3,032. However, when analyzing only those studies with nonarthritic patellae, the incremental cost per QALY to resurface the patella increased to $183,584. CONCLUSION: Patellar resurfacing remains a controversial issue in TKA. Utilizing data from new prospective randomized studies, this analysis finds that routinely resurfacing arthritis-free patellae in TKA are not cost-effective.

Do Standard Surgical Guides Produce Accurate and Precise Femoral Bone Resections During Total Knee Arthroplasty?

PURPOSE: Accurate alignment and balanced flexion and extension gaps are critical elements in achieving a successful outcome following total knee arthroplasty (TKA). The ability to make accurate and precise bone cuts is essential in the creation of balanced gaps. We sought to determine if one type of modern-day standard surgical instrument using an intramedullary rod and posterior referencing produces accurate and precise distal and posterior femoral bone resections. MATERIALS AND METHODS: Seventy-five consecutive patients undergoing TKA were divided into three groups, with 25 patients in each group receiving one of three implant designs: 25 Stryker Triathlon® CR (Stryker, Mahwah, NJ), 25 Zimmer NexGen® Flex CR (Zimmer, Warsaw, IN), and 25 StelKast Proven Gen-FlexTM CR (StelKast, Pittsburgh, PA). Flexion-extension gap matching was determined using only the medial flexion and extension gaps. Accuracy was determined by comparing actual resection thickness to desired resection thickness. "Optimal" accuracy was considered to be within 1.0mm of desired, and "near-optimal" accuracy was considered to be within 2.0mm of the desired resection thickness. Precision was determined by the variability of resection thicknesses within each system. RESULTS: Data demonstrated a lack of accuracy and precision across all three tested systems, with each system resulting in certain unique tendencies. Only one out of 75 cases resulted in optimal resection accuracy with all three cuts (Zimmer). When lowering the threshold to include both optimal and near-optimal (within 2 mm of error) with all three cuts, only one third of Stryker and Zimmer cases and two thirds of StelKast cases achieved this threshold, representing 44% of cases (33/75). CONCLUSIONS: Improvements in instrumentation to increase accuracy and precision may be warranted. Errors in fixation may be due to the instrumentation itself, and altering instrumentation to include less modularity, provide more stable fixation, and more reliably seal the implant on the femur may be of benefit.

Interleukin receptor-associated kinase (IRAK-4) deficiency associated with bacterial infections and failure to sustain antibody responses.

We previously described a girl with recurrent episodes of pneumococcal pneumonia with septicemia and other infections,(1) found to have interleukin-1 receptor-associated kinase 4 deficiency (IRAK-4) deficiency.(2) In this report, we show that our patient is unable to sustain antibody responses either to polysaccharide or protein antigens or to a neoantigen-bacteriophage.