Discontinuation of the liposomal delivery of bupivacaine has no effect on pain management after primary total knee arthroplasty : no effect on pain scores, opioid consumption, or functional status.

AIMS: Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. METHODS: On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. RESULTS: A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). CONCLUSION: The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J 2021;103-B(6 Supple A):102-107.

Utilization of a Novel Opioid-Sparing Protocol in Primary Total Hip Arthroplasty Results in Reduced Opiate Consumption and Improved Functional Status.

BACKGROUND: Total hip arthroplasty (THA) candidates have historically received high doses of opioids within the perioperative period; however, the amounts are being continually reduced as awareness of opioid abuse spreads. Here we seek to evaluate the effectiveness of a novel opiate-sparing protocol (OSP) for primary THAs in reducing opiate administrations, while maintaining similar levels of pain control and postoperative function. METHODS: All patients undergoing primary THA between January 1, 2019 and June 30, 2019 were placed under a novel OSP. Data were prospectively collected as part of standard of care. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalences (MMEs) per patient encounter per 24-hour interval. Postoperative pain and functional status were assessed as secondary outcomes using the Verbal Rating Scale for pain and the Activity Measure for Post-Acute Care scores, respectively. RESULTS: One thousand fifty primary THAs had received our institution's OSP, and 953 patients were utilized as our historical control. OSP patients demonstrated significantly lower 0-24, 24-48, and 48-72 hours with less opiate administration variance (total MME: Control 75.55 ± 121.07 MME vs OSP 57.10 ± 87.48 MME; 24.42% decrease, P < .001). Although pain scores reached statistical significance between 0 and 12 (Control 2.09 vs OSP 2.36, P < .001), their differences were not clinically significant. Finally, OSP patients demonstrated a trend toward higher Activity Measure for Post-Acute Care scores across all 6 domains (total scores: Control 20.53 ± 3.67 vs OSP 20.76 ± 3.64, P = .18). CONCLUSION: Implementation of an OSP can significantly decrease the utilization of opioids in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining a comparable and non-inferior level of pain and function.

Tramadol in Knee Osteoarthritis: Does Preoperative Use Affect Patient-Reported Outcomes After Total Knee Arthroplasty?

BACKGROUND: The 2013 American Academy of Orthopedic Surgeons evidence-based guidelines recommend against the use of preoperative narcotics in the management of symptomatic osteoarthritic knees; however, the guidelines strongly recommend tramadol in this patient population. To our knowledge, no study to date has evaluated outcomes in patients who use tramadol exclusively as compared with narcotics naive patients. METHODS: This is a retrospective study of prospectively collected data for patients who underwent unilateral primary total knee arthroplasty between January 2017 and March 2018. PRO scores were obtained using a novel electronic patient rehabilitation application, which pushed PRO surveys via email and mobile devices within 1 month prior to surgery and 3 months postoperatively. RESULTS: One hundred and thirty-six patients were opiate naïve, while 63 had obtained narcotics before the index operation. Of those, 21 patients received tramadol. The average preoperative Knee Disability and Osteoarthritis Outcome Scores were 50.4, 49.95, and 48.01 for the naïve, tramadol, and narcotic populations, respectively, (P = .60). The tramadol cohort had the least gain in 3 months postoperative Knee Disability and Osteoarthritis Outcome Scores, improving on average 12.5 points in comparison to the 19.1 and 20.1 improvements seen in the narcotic and naïve cohorts, respectively (P = .09). This difference was statistically significant when comparing the naïve and tramadol populations alone in post hoc analysis (P = .016). CONCLUSIONS: When comparing patients who took tramadol preoperatively to patients who were opiate naïve, patients that used tramadol trended toward significantly less improvement in functional outcomes in the short-term postoperative period.

Comparison of phacoemulsification parameters between manual and femtosecond laser-assisted cataract surgery.

OBJECTIVE: To compare the nucleus removal time (NRT) and cumulative dissipated energy (CDE) outcomes of traditional phacoemulsification and femtosecond laser-assisted cataract surgery (FLACS) performed by cornea attendings and fellows. DESIGN: Prospective nonrandomized comparative study. PARTICIPANTS: A total of 410 eyes of 410 patients. METHODS: Nucleus removal time and CDE were recorded from patients who underwent cataract surgery using either FLACS (Catalys, LenSx, or Victus) or traditional phacoemulsification technique performed by 3 cornea attendings and 4 cornea fellows. One-way analysis of variance with Bonferroni post hoc tests and unpaired t tests were used to determine the differences between groups. RESULTS: There was no statistically significant difference in cataract grade between groups. NRT was significantly lower only when using the Catalys system compared with the LenSx and Victus platforms and the traditional surgery, in both the attending group (p = 0.006, p = 0.002, p < 0.000, respectively) and the fellow group (p = 0.049, p = 0.038, p = 0.011, respectively). With respect to CDE, there was no significant difference when using the laser systems compared with the traditional surgery in both attending and fellow groups (p > 0.05). NRT and CDE were significantly higher in the fellow group (NRT = 269.10 ± 117.67, CDE = 7.30 ± 4.83) compared with the attending group (NRT = 218.87 ± 109.67, CDE = 5.76 ± 3.66) in traditional cases; however, in FLACS cases, there was no significant difference in NRT and CDE between the fellow group and the attending group. CONCLUSIONS: Inexperienced surgeons seem to require more time and use more ultrasound energy during traditional phacoemulsification when compared with experienced surgeons. The use of FLACS seems to significantly improve the NRT of experienced and inexperienced surgeons.

The Effect of NSAID Pretreatment on Aqueous Humor Prostaglandin E2 Concentration in Eyes Undergoing Femtosecond Laser-Assisted Capsulotomy.

PURPOSE: To assess aqueous humor concentration of prostaglandin E2 (PGE2) after capsulotomy creation using a femtosecond laser (FLAC) in patients pretreated with short-term topical ketorolac versus patients without pretreatment. METHODS: This prospective study comprised consecutive patients scheduled to undergo cataract surgery using a femtosecond laser platform to perform only capsulotomies. An identical protocol for preoperative mydriasis was used for all the eyes included in the study, while aqueous humor was extracted from the anterior chamber of all patients immediately after the initial side port incision. ELISA was performed to quantify aqueous humor PGE2. The patients were divided into 2 groups; in group 1, the patients received short-term topical ketorolac preoperatively, while the patients in group 2 did not receive NSAID pretreatment. RESULTS: Twenty eyes of 20 patients were included in the study (10 eyes in each group). Mean concentration of aqueous humor PGE2 after FLAC was 392.16 ± 162.00 pg/ml and 622.63 ± 331.84 pg/ml for groups 1 and 2, respectively. A statistically significant difference in aqueous humor PGE2 concentration between the two groups (p < 0.05) was demonstrated, with the eyes that received ketorolac pretreatment demonstrating a lower concentration of PGE2. CONCLUSION: Short-term topical use of ketorolac prior to FLAC seems to prevent excessive release of PGE2 in the anterior chamber of the eyes that received NSAID pretreatment when compared to the eyes that did not receive NSAIDs preoperatively.

Effects of Short-term Preoperative Topical Ketorolac on Pupil Diameter in Eyes Undergoing Femtosecond Laser-Assisted Capsulotomy.

PURPOSE: To assess pupil diameter before and after femtosecond laser-assisted capsulotomy in patients who were pretreated with a short-term topical nonsteroidal anti-inflammatory drug (NSAID) (ketorolac) versus those without pretreatment. METHODS: This prospective, randomized, observational case series included consecutive patients scheduled to undergo cataract extraction using the Catalys femtosecond laser platform (Abbott Medical Optics, Inc., Santa Ana, CA) to perform only capsulotomies. The same protocol for preoperative medical mydriasis was used for all patients, whereas pupil diameter was assessed using a surgical ruler immediately before and 3 minutes after femtosecond laser-assisted capsulotomy. The patients were divided into two groups: one received short-term topical ketorolac preoperatively and the other did not receive NSAID pretreatment (control). RESULTS: A total of 42 eyes of 42 patients (1 eye per patient) were included in the study. Mean pupillary miosis was 0.79 ± 1.08 and 1.57 ± 1.19 mm for the ketorolac and control groups, respectively. There was a statistically significant decrease in pupil diameter for both groups individually (P < .05). There was also a statistically significant difference between the two groups (P < .05) with the induced miosis in the eyes that did not receive topical NSAIDs prior to cataract extraction being twofold greater when compared with the miosis of the eyes that received ketorolac pretreatment. CONCLUSIONS: Short-term topical use of ketorolac prior to femtosecond laser-assisted cataract surgery seems to induce significantly less pupillary miosis in comparison to eyes that did not receive NSAID pretreatment. NSAID use is advised prior to femtosecond laser-assisted cataract surgery to minimize pupil miosis-related surgical difficulties or complications during cataract extraction. [J Refract Surg. 2017;33(4):230-234.].

Differences in energy expenditure for conventional and femtosecond-assisted cataract surgery using 2 different phacoemulsification systems.

PURPOSE: To compare the mean cumulative dissipated energy (CDE) in patients having femtosecond laser-assisted or conventional phacoemulsification cataract surgery using 2 different phacoemulsification platforms. SETTING: Bascom Palmer Eye Institute, Miami, Florida, USA. DESIGN: Prospective comparative nonrandomized clinical study. METHODS: Consecutive patients were scheduled to have femtosecond laser-assisted cataract surgery with the Lensx laser or conventional phacoemulsification using an active-fluidics torsional platform (Centurion) or torsional platform (Infiniti). The mean CDE and cataract grade were recorded. RESULTS: The study comprised 570 eyes (570 patients). There was no statistically significant difference in mean age (P = .41, femtosecond group; P = .33, conventional group) or cataract grade (P = .78 and P = .45, respectively) between the active-fluidics and gravity-fluidics platforms. In femtosecond cases (145 eyes), the mean CDE (percent-seconds) was 5.18 ± 4.58 (SD) with active fluidics and 7.00 ± 6.85 with gravity fluidics; in conventional cases (425 eyes), the mean CDE was 7.77 ± 6.97 and 11.43 ± 9.12, respectively. In both femtosecond cases and conventional cases, the CDE was lower with the active-fluidics platform than with the gravity-fluidics platform (P = .029, femtosecond group; P < .001 conventional group). With both fluidics platforms, the mean CDE was significantly lower in the femtosecond group than in the conventional group (both P < .001). CONCLUSIONS: The active-fluidics phacoemulsification platform achieved lower CDE values than the gravity-fluidics platform for conventional cataract extraction. Femtosecond laser pretreatment with the active-fluidics platform further reduced CDE.

Causes and correction of dissatisfaction after implantation of presbyopia-correcting intraocular lenses.

PURPOSE: The purpose of this study was to assess the causes and possible solutions for patient dissatisfaction after the implantation of presbyopia-correcting intraocular lenses (IOLs). METHODS: This study was a retrospective review of clinical records. All patients who were seen between January 2009 and December 2013 whose primary reason for consultation was dissatisfaction with visual performance after presbyopia-correcting IOL implantation were included in the study. A single treating physician, who determined the most probable cause of dissatisfaction, decided which interventions to pursue following the initial consultation. RESULTS: Data from 74 eyes of 49 patients were analyzed. The most common cause for complaint was blurry or foggy vision both for distance and near (68%). Complaints were most frequently attributed to residual refractive error (57%) and dry eye (35%). The most common interventions pursued were treatment of refractive error with glasses or contact lenses (46%) and treatment for dry eye (24%). Corneal laser vision correction was done in 8% of eyes; 7% required an IOL exchange. After the interventions, 45% of patients had completed resolution of symptoms, 23% of patients were partially satisfied with the results, and 32% remained completely dissatisfied with the final results. CONCLUSION: The most identifiable causes of dissatisfaction after presbyopia-correcting IOL implantation are residual refractive error and dry eye. Most patients can be managed with conservative treatment, though a significant number of patients remained unsatisfied despite multiple measures.

The Effect of LASIK on Timing of Cataract Surgery.

PURPOSE: To compare the age at the time of cataract surgery in patients who have undergone microkeratome-assisted LASIK versus individuals matched for axial length, cataract grade, and visual acuity with no history of refractive surgery. METHODS: Retrospective chart review of patients who underwent cataract extraction between September 2013 and March 2015 at the Bascom Palmer Eye Institute. Patients had a history of either microkeratome-assisted LASIK or no prior ocular surgery. Corrected distance visual acuity (CDVA) before and after cataract extraction, uncorrected distance visual acuity (UDVA) before cataract extraction, gender, axial length, and cataract grade were assessed, along with age at the time of LASIK, age at the time of cataract extraction, and the time lapse between LASIK and cataract extraction. RESULTS: Fifty eyes of 38 patients were included in the LASIK group and 155 eyes of 136 patients were included in the control group. There was no significant difference between these groups with respect to gender (P = .87), CDVA before cataract extraction (P = .11), UDVA before cataract extraction (P = .09), axial length (P = .67), and cataract grade (P = .46). Mean age at the time of cataract extraction for patients in the LASIK group and control group were 64 ± 7 and 73 ± 8 years, respectively (P < .005). Negative correlations were found between age at time of cataract extraction and axial length in the LASIK and control groups (r = -0.18, P = .20 vs r = -0.36, P =. 01, respectively). CONCLUSIONS: Microkeratome-assisted LASIK seems to be correlated with earlier cataract extraction. Patients with a history of microkeratome-assisted LASIK under-went cataract surgery a decade sooner than patients with similar demographic and ocular characteristics. [J Refract Surg. 2016;32(5):306-310.].