Peripheral nerve blocks such as a femoral + sciatic block have demonstrated significant pain relief following TKA. However, these nerve blocks have residual motor deficits which prevent immediate postoperative ambulation. The purpose of this study was to compare outcomes in patients undergoing primary TKA with femoral and sciatic (Fem + Sci) motor nerve blocks versus an adductor canal and the interspace between the popliteal artery and the capsule of the posterior knee and adductor canal block (IPACK + ACB) sensory nerve blocks. A total of 100 consecutive patients were reviewed, 50 received Fem + Sci nerve blocks and 50 received IPACK + ACB blocks preoperatively. There were no differences in the two groups with respect to surgical technique, implant type, postoperative pain, and physical therapy protocols. Differences in opioid requirements, length of stay (LOS), distance walked, and common knee scoring systems were analyzed. Among them, 62% IPACK + ACB patients were discharged on postoperative day 1 compared with 14% in the Fem + Sci group (p < 0.0001). The IPACK + ACB patients had a shorter LOS (mean 1.48 days vs. 2.02 days, p < 0.001), ambulated further on postoperative day 0 (mean 21.4 feet vs. 5.3 feet, p < 0.001), and required less narcotics the day after surgery (mean, 15.7 vs. 24.0 morphine equivalents p < 0.0001) and at 2 weeks (mean, 6.2 vs. 9.3 morphine equivalents, p = 0.025). The use of this combination IPACK and ACB demonstrated improved early ambulation with a decrease in opioid use and length of stay compared with a femoral and sciatic motor nerve block in patients undergoing primary TKA.
Analgesics, Opioid , Arthroplasty, Replacement, Knee/adverse effects , Length of Stay , Aged , Aged, 80 and over , Anesthetics, Local , Female , Femoral Nerve/surgery , Humans , Knee/surgery , Knee Joint/surgery , Male , Middle Aged , Morphine , Nerve Block/methods , Pain Management , Pain, Postoperative/etiology , Patient Discharge , Popliteal Artery
PURPOSE OF REVIEW: With the unprecedented advancement of data aggregation and deep learning algorithms, artificial intelligence (AI) and machine learning (ML) are poised to transform the practice of medicine. The field of orthopedics, in particular, is uniquely suited to harness the power of big data, and in doing so provide critical insight into elevating the many facets of care provided by orthopedic surgeons. The purpose of this review is to critically evaluate the recent and novel literature regarding ML in the field of orthopedics and to address its potential impact on the future of musculoskeletal care. RECENT FINDINGS: Recent literature demonstrates that the incorporation of ML into orthopedics has the potential to elevate patient care through alternative patient-specific payment models, rapidly analyze imaging modalities, and remotely monitor patients. Just as the business of medicine was once considered outside the domain of the orthopedic surgeon, we report evidence that demonstrates these emerging applications of AI warrant ownership, leverage, and application by the orthopedic surgeon to better serve their patients and deliver optimal, value-based care.
BACKGROUND: Changes in reimbursement in total knee arthroplasty (TKA) by Centers for Medicare and Medicaid Services (CMS) have been tied to a perceived decrease in the total surgical time required to perform these operations. However, little information is available to CMS about recorded surgical times for TKA across the United States and the variables that drive these values. Therefore, the purpose of our study, is to evaluate (1) changes in operative time over time and (2) factors associated with variations in operative time. METHODS: The National Surgical Quality Improvement Program database was queried to identify all primary TKAs conducted between January 1, 2008, and December 31, 2017. All TKAs conducted within our study period that had operative time data available were included. Multivariable linear models were created to assess factors that influence operative time over the study period. RESULTS: Our final analysis included 140,890 TKAs. The mean operative time across the study period was found to be 92.60 minutes. Examining quarterly values, operative time stayed within 5 minutes of this mean (range, 89.80-97.51 minutes). Age, sex, functional status, anesthesia type, body mass index, operative year, transfusion requirements, and preoperative laboratory findings significantly influenced operative time (P < .05 for all). CONCLUSION: Our analysis indicates that while there are numerous factors that influence procedure duration, operative times have remained stable. This information should be heavily considered in regard to physician reimbursement, because providers are maintaining operative times and work effort while mitigating factors that influence outcomes in the perioperative period.
Arthroplasty, Replacement, Knee , Aged , Humans , Medicare , Operative Time , Quality Improvement , Time , United States
Objective: There are many approaches to nipple-areola complex reconstruction. Tissue quality and thickness, desired nipple location and size, scar position, and surgeon preference all play a role in selecting a technique. We present the rectangle-to-cube nipple flap, a new technique for challenging nipple reconstruction. A review of published techniques is compared and contrasted with this flap design. Methods: Following bilateral total skin-sparing mastectomies, a patient with breast cancer underwent breast reconstruction with tissue expanders and subsequent nipple reconstruction with the rectangle-to-cube nipple flap. An inferiorly based rectangular flap with medial and lateral extensions is designed inferior to the transverse scar. Upon elevation and rotation, the medial and lateral flaps form a cube. Results: In all cases of rectangle-to-cube nipple flaps performed at our institution, adequate nipple projection and patient satisfaction have been achieved at 2-month postoperative evaluation. Conclusion: The rectangle-to-cube nipple flap provides sustained nipple projection due to the de-epithelialized base on which the flap sits. The rectangle-to-cube nipple flap also takes advantage of a long transverse scar, and it can be extended to include longer scars for scar revisions.
Background: An estimated 125,711 face-lifts and 54,281 neck-lifts were performed in 2015. Regardless of the technique employed, facial and neck flap elevation carries with it anatomical risk of which any surgeon performing these procedures should be aware of. Statistics related to anterior jugular vein injury during these procedures have not been published. Objective: To define a "danger zone" that will contain both of the anterior jugular veins on the basis of anatomical landmarks to aid surgeons with planning their surgical approach during rhytidectomy in the anterior neck region. Methods: Ten fresh tissue heminecks were dissected. All specimens were dissected under loupe magnification in a 45° (face-lift) position in which a midline incision was used for exposure. Measurements from the anterior jugular vein to the hyoid, thyroid cartilage, and cricoid cartilage bilaterally were taken. The transverse distance between the anterior jugular veins at the level of the hyoid, thyroid cartilage, and cricoid cartilage was also measured. Results: The anterior jugular veins remain in an anatomical danger zone while they travel in the anterior neck. Regardless of anatomical variation of the vessels between bodies, they generally reside in this danger zone from their inferior emergence behind the sternocleidomastoid muscle until they branch in the suprahyoid region. Conclusions: Knowledge of the anatomy, course, and location of the anterior jugular veins through the anterior neck based on anatomical landmarks and distance ratios can facilitate a safer dissection during rhytidectomy procedures.
Background: The goals of fingertip reconstruction are to achieve adequate soft-tissue coverage and a functional nail plate and to maintain sensation, proprioception, and cosmesis. Objective: We present a composite tissue graft and volar V-Y advancement flap for reconstruction of a traumatic amputation of a fingertip, which provided optimal preservation of the hyponychium and the volar pad for prevention of a hook nail. Historically, composite fingertip grafts have not been recommended for adults with large defects. Methods: The amputated nail bed, hyponychium, and a 10 × 20-mm segment of the fingertip were utilized as a composite graft for reconstruction of the nail bed in an adult. The addition of a volar V-Y advancement flap to reconstruct the fingertip was necessary for complete soft-tissue reconstruction. Results: The reconstruction resulted in nail plate adhesion without significant nail deformity and a functional and sensate fingertip. Conclusion: Components of amputated fingertips including the sterile matrix, hyponychium, and part of the fingertip can be utilized in a composite graft to yield satisfactory functional and cosmetic results in adults.
Objective: Physicians should be aware of patients trying to obtain a diagnosis for secondary gain. Malingering is a diagnosis that should be suspected when objective findings do not support the subjective symptoms and there is secondary gain. Methods: A series of 21 cases are presented that support this position. The charts of 21 patients with a diagnosis of reflex sympathetic dystrophy (chronic regional pain syndrome) and nonanatomic findings were evaluated. Results: The patients in this series were found to be malingering based on discrepancies between subjective symptoms and objective findings. Conclusions: The diagnosis of malingering should be based on thorough history, physical examination, electrodiagnostic studies, imaging studies, and evaluation of all medical records.
