Current Strategies in Pain Regimens for Robotic Urologic Surgery: A Comprehensive Review.

Context: Robotic surgery is becoming the most common approach in minimally invasive urologic procedures. Robotic surgery offers less pain to patients because of smaller keyhole incisions and less tissue retraction and stretching of fascia and muscular fibers. Tailored pain regimens have also evolved and allowed patients to feel minimal to no discomfort after robotic urologic surgery, allowing in parallel better surgical outcomes. This study aims to analyze the most current pain regimens in robotic urologic surgery and to evaluate the most current pain protocols and corresponding outcomes. Evidence Acquisition: A literature review was performed of published manuscripts utilizing Pubmed and Google Scholar on pain protocols for patients undergoing robotic urologic surgery. Results: Multimodal analgesia is gaining ground in robotic urologic surgery. Regional analgesia includes four major modalities: Neuroaxial analgesia, intercostal blocks, tranvsersus abdominis plane blocks, and paravertebral blocks. Each approach has a different injection site, region of analgesia coverage, and duration of coverage depending upon local anesthesia and/or adjuvant utilized with advantages and disadvantages that make each modality unique and efficacious. Conclusions: Robotic urologic surgery has offered the advantage of smaller incisions, faster recovery, less postoperative opioid consumption, and better surgical outcomes. Neuraxial, intercostal, transversus abdominis plane, and quadratus lumborum blocks are the best and most adopted approaches which offer optimal outcomes to patients.

An integrated educational and multimodal approach to achieving an opioid-free postoperative course after arthroscopic rotator cuff repair.

BACKGROUND: In the realm of shoulder surgery, arthroscopic rotator cuff repair (RCR) is one of the most painful procedures and is often associated with higher opioid consumption. The purpose of this study was to evaluate effectiveness of preoperative and postoperative patient education and multimodal pain management to achieve an opioid-free postoperative recovery after RCR. METHODS: Sixty patients who underwent RCR were divided in 2 groups. All patientsreceived an interscalene nerve block and multimodal pain management. The opioid intervention group (OIG) in addition received preoperative education on expectations of pain, non opioid pain protocols, and alternate therapiesto minimize pain as well as customized postoperative instructions. Patients were compared on pain levels, opioid consumption, and outcomes scores preoperatively and at 48 hours, 2 weeks, and final follow-up. Patient-reported outcomes and opioid usage were compared and analyzed using student's t-tests and logistic regression. RESULTS: At 48 hours, 15% of OIG patients reported use of rescue opioids after surgery compared with 100% of control group patients. Zero percent of OIG patients reported opioid use at 2 weeks compared to 90% of control group patients (P = .0196). Patients in both groups showed significant improvements in all outcome scores (P ≤ .05). At 6 weeks, functional, Constant, and satisfaction outcome scores were all higher in the OIG (P < .05). At last follow-up, there were no significant differences for all patient-reported outcomes between groups. CONCLUSIONS: Application of patient education tools and innovative multimodal pain management protocols successfully eliminates the need for opioids while maintaining excellent patient satisfaction and outcomes.

The Practice of Overlapping Surgery Is Safe in Total Knee and Hip Arthroplasty.

BACKGROUND: Overlapping surgery occurs when a surgeon performs 2 procedures in an overlapping time frame. This practice is commonplace in the setting of total joint arthroplasty and is intended to increase patient access to experienced surgeons, improve efficiency, and advance the surgical competence of surgeons and trainees. The practice of overlapping surgery has been questioned because of safety and ethical concerns. As the literature is scarce on this issue, we evaluated the unplanned hospital readmission and reoperation rates associated with overlapping and non-overlapping total joint arthroplasty procedures. METHODS: We reviewed 3,290 consecutive primary total knee and hip arthroplasty procedures that had been performed between November 2010 and July 2016 by 2 fellowship-trained senior surgeons at a single institution. Overlapping surgery was defined as the practice in which the attending surgeon performed a separate procedure in another room with an overlapping room time of at least 30 minutes. Patient baseline characteristics and 90-day rates of complications, readmissions, and reoperations were compared between overlapping and non-overlapping procedures. Subanalyses also were done on patients with a body mass index (BMI) of ≥30 kg/m2 and those with an American Society of Anesthesiologists (ASA) score of 3 or 4. The level of significance was set at 0.05. RESULTS: Of the 2,833 procedures that met the inclusion criteria, 57% (1,610) were overlapping and 43% (1,223) were non-overlapping. Baseline demographics, BMI, and ASA scores were similar between the groups. No significant differences were found between the overlapping and non-overlapping procedures in terms of the 90-day rates of complications (5.2% vs. 6.6%, respectively; p = 0.104), unplanned readmissions (3.4% vs. 4.3%; p = 0.235), or reoperations (3.1 vs. 3.1; p = 1.0) in the analysis of the entire cohort or in subgroup analyses of obese patients and patients with an ASA score of 3 or 4. The total mean operating room time was 5.8 minutes higher for overlapping procedures. CONCLUSIONS: Overlapping procedures showed no increase in terms of the 90-day rates of complications, readmissions, or reoperations when compared with non-overlapping procedures. There was just over a 5-minute increase in mean operating room time for overlapping procedures. Our data suggest that overlapping surgery does not lead to detrimental outcomes following total knee arthroplasty or total hip arthroplasty. Future investigations evaluating patient-oriented outcomes and satisfaction are warranted. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Concussion rates and effects on player performance in Major League Baseball players.

BACKGROUND: Major League Baseball (MLB) players are throwing the ball faster and hitting harder than ever before. Although some safety measures have been implemented, by decreasing the 15 days on the disabled list (DL) to the 7 days on the DL, concussion rates remain high across positions and may impact player performance. Our hypothesis was, there would be an increase in concussion incidence following implementation of the 7 day DL, but this would not have a negative impact on player's postconcussion performance. STUDY DESIGN: This is a descriptive epidemiology study. METHODS: The concussed players from 2005 to 2016 were identified from the MLB DL and verified using established new sources. Position-specific performance metrics from before and after injuries were gathered and compared to assess effects of the injury. Postconcussion performance metrics were compared before and after the 7-day DL rule implementation. RESULTS: A total of 112 concussed players were placed on the DL. For all position players, the batting average (BA) and on-base percentage (OBP) showed a nonsignificant decline after injury (P=0.756). Although performance statistics for pitchers declined on average, the trend was not statistically significant. Postinjury BA and OBP did not significantly change before (0.355) and after (0.313) the 7-day DL rule change in 2011 (P=0.162). CONCLUSION: The incidence of reported concussion has increased with the 7-day DL rule change. Concussion incidence was highest in catchers and pitchers compared with all other players. The most common causes identified as being hit by pitch or struck by a foul ball or foul tip. While new league rules prevent collisions with catchers at home plate, injury by a foul tip was the most common cause for concussion. The shortened time spent on the DL did not negatively impact player's performance. Further research on protective helmets for catchers may reduce concussion incidence.