Inpatient Opioid Consumption Variability following Total Knee Arthroplasty: Analysis of 4,038 Procedures.

This study examined an early iteration of an inpatient opioid administration-reporting tool, which standardized patient opioid consumption as an average daily morphine milligram equivalence per surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. The objective was to assess the variability of inpatient opioid administration rates among surgeons after implementation of a multimodal opioid sparing pain protocol. We queried the electronic medical record at our institution for patients undergoing elective primary TKA between January 1, 2016 and June 30, 2018. Patient demographics, inpatient and surgical factors, and inpatient opioid administration were retrieved. Opioid consumption was converted into average MME for each postoperative day. These MME/day/encounter values were used to determine mean and variance of opioids prescribed by individual surgeons. A secondary analysis of regional inpatient opioid consumption was determined by patient zip codes. In total, 23 surgeons performed 4,038 primary TKA. The institutional average opioid dose was 46.24 ± 0.75 MME/day/encounter. Average intersurgeon (IS) opioid prescribing ranged from 17.67 to 59.15 MME/day/encounter. Intrasurgeon variability ranged between ± 1.01 and ± 7.51 MME/day/encounter. After adjusting for patient factors, the average institutional MME/day/encounter was 38.43 ± 0.42, with average IS variability ranging from 18.29 to 42.84 MME/day/encounter, and intrasurgeon variability ranging between ± 1.05 and ± 2.82 MME/day/encounter. Our results suggest that there is intrainstitutional variability in opioid administration following primary TKA even after controlling for potential patient risk factors. TKA candidates may benefit from the implementation of a more rigid standardization of multimodal pain management protocols that can control pain while minimizing the opioid burden. This is a level of evidence III, retrospective observational analysis.

Team Approach: Evaluation and Management of Low-Grade Cartilaginous Lesions.

¼ Assessment of chondral lesions begins with a clinical evaluation and radiographs. ¼ Longitudinal follow-up with serial radiographs is appropriate in cases without evidence of aggressive radiographic features. ¼ Concerning radiographic features include periosteal reaction, soft-tissue extension, cortical destruction, endosteal scalloping of greater than two-thirds of the native cortex, larger lesion size (≥5 cm), and location in the axial skeleton. ¼ Biomarkers such as IMP3, SOX4, microRNA, and periostin may be used as an adjunct in histologic assessment to help differentiate benign enchondroma from a low-grade chondrosarcoma. ¼ Advanced-imaging studies, such as computed tomography (CT), bone scans, magnetic resonance imaging (MRI), dynamic contrast-enhanced MRI, and fluorodeoxyglucose positron emission tomography (FDG-PET), may be considered for borderline cases. ¼ Aggressive or concerning radiographic features should prompt evaluation with advanced imaging or referral to an orthopaedic oncologist.

Indolent Propionibacterium acnes infection associated with orthopedic hardware in the ankle: A case report and literature review.

Propionibacterium acnes (P. acnes) infections of the foot and ankle are very rare and require a unique approach to prevention, diagnosis, and treatment. Clinicians should consider P. acnes as a cause for all late and indolent orthopedic infections, as appropriate surgical and medical management can result in a good outcome.

Safe Zones for Anterior Acetabular Retractor Placement in Direct Anterior Total Hip Arthroplasty: A Cadaveric Study.

INTRODUCTION: There is paucity of literature evaluating anterior acetabular retractor proximity to the femoral nerve and external iliac vessels during total hip arthroplasty through the direct anterior approach. In this cadaveric study, we evaluated three retractor locations to identify optimal positioning of anterior retractors. METHODS: A direct anterior approach was performed in 22 hips of 15 cadavers. Anterior acetabular retractors were placed over the anterior acetabular wall in-line with the femoral neck (12-o'clock or middle position). The anterior neurovascular structures were identified through the ilioinguinal approach. Retractors were reinserted at 10-o'clock (right hip; superior) and 2-o'clock (right hip; inferior) locations marked using K-wires. Horizontal and vertical distances from retractor tip positions to neurovascular structures were measured with a digital caliper. RESULTS: Retractor tips moved significantly from lateral to the femoral nerve when placed in the superior position (mean, 2.8 mm) to medial to the femoral nerve in the middle (mean, -2.3 mm) and inferior (mean, -4.8 mm) locations. Retractor tips moved significantly medial toward the external iliac artery when retractors were moved from superior (mean, 15.3 mm) to inferior (mean, 6.6 mm) positions placing the retractor tip closer to the vessels. CONCLUSION: As retractor placements moved inferior, retractor tips moved medial to neurovascular structures. Inferior retractor positioning placed the femoral nerve and external iliac artery at the risk of injury during the initial retractor placement or adjustment. Retractors should be placed in a relative safe zone superior to the 12-o'clock position to avoid damage to neurovascular structures. LEVEL OF EVIDENCE: IV.