Expanding the perioperative lens: Does the end justify the means?

In 1994, Fischer et al. established the preoperative clinic for the perioperative services at Stanford University Medical Center. By lowering the risk of cancellation and reducing morbidity and mortality against the push to move surgeries to an outpatient, basis, they demonstrated a return on investment.

What Is the Role of a Periarticular Injection for Knee Arthroplasty Patients Receiving a Multimodal Analgesia Regimen Incorporating Adductor Canal and Infiltration Between the Popliteal Artery and Capsule of the Knee Blocks? A Randomized Blinded Placebo-Controlled Noninferiority Trial.

Background: Optimal analgesic protocols for total knee arthroplasty (TKA) patients remain controversial. Multimodal analgesia is advocated, often including peripheral nerve blocks and/or periarticular injections (PAIs). If 2 blocks (adductor canal block [ACB] plus infiltration between the popliteal artery and capsule of the knee [IPACK]) are used, also performing PAI may not be necessary.

The Use of Critical Care Services After Orthopedic Surgery at a High-Volume Orthopedic Medical Center: A Retrospective Study.

With an aging population, orthopedics has become one of the largest and fastest growing surgical fields. However, data on the use of critical care services (CCS) in patients undergoing orthopedic procedures remain sparse. We sought to elucidate the prevalence and characteristics of patients requiring CCS and intermediate levels of care after orthopedic surgeries at a high-volume orthopedic medical center.

Effect of anterior approach compared to posterolateral approach on readiness for discharge and thrombogenic markers in patients undergoing unilateral total hip arthroplasty: a prospective cohort study.

Introduction: The direct anterior approach (DAA) for total hip arthroplasty (THA) is considered less invasive than the posterolateral approach (PLA), possibly leading to earlier mobilization, faster recovery, and lower levels of thrombogenic markers. The purpose of the current study was to prospectively compare readiness for discharge, rehabilitation milestones, markers of thrombosis and inflammation at 6 weeks postoperatively between DAA and PLA.

Methods: A total of 40 patients (20 anterior and 20 posterolateral) were prospectively enrolled.

Development and Internal Validation of Machine Learning Algorithms for Predicting Hyponatremia After TJA.

Background: The development of hyponatremia after total joint arthroplasty (TJA) may lead to several adverse events and is associated with prolonged inpatient length of stay as well as increased hospital costs. The purpose of this study was to develop and internally validate machine learning algorithms for predicting hyponatremia after TJA.

Methods: A consecutive cohort of 30,703 TJA patients from an institutional registry at a large, tertiary academic hospital were included.

Perioperative Nonsteroidal Anti-Inflammatory Agents in the COVID-19 Orthopedic Patient.

Background: SARS-CoV-2 infection can cause serious complications beyond lung injury and respiratory failure, including sepsis, cardiovascular injury, renal failure, coagulation abnormalities, and neurologic injury. Widely used medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) have been flagged as having the potential to cause harm in the context of COVID-19. It is unknown if the benefits of NSAID use in the orthopedic population will outweigh the potential risks of increased morbidity in COVID-19 orthopedic patients.

Comparison of Topical and Intravenous Tranexamic Acid for Total Knee Replacement: A Randomized Double-Blinded Controlled Study of Effects on Tranexamic Acid Levels and Thrombogenic and Inflammatory Marker Levels.

Background: Tranexamic acid (TXA) is an antifibrinolytic drug. Topical administration of TXA during total knee arthroplasty (TKA) is favored for certain patients because of concerns about thrombotic complications, despite a lack of supporting literature. We compared local and systemic levels of thrombogenic markers, interleukin (IL)-6, and TXA between patients who received intravenous (IV) TXA and those who received topical TXA.

A comparison of two different concentrations and infusion rates of ropivacaine in perineural infusion administered at the same total dose for analgesia after foot and ankle surgery: a randomized, double blinded, controlled study.

Background: Continuous popliteal nerve block is utilized for postoperative analgesia after foot and ankle surgery. Whether only the total dose of local anesthetic or the combination of concentration and volume determine the characteristics of a continuous popliteal nerve infusion remains currently unknown. We hypothesized a reduction of the incidence of insensate extremity in patients given ropivacaine 0.

Clinical Indicators of the Need for Telemetry Postoperative Monitoring in Patients With Suspected Obstructive Sleep Apnea Undergoing Total Knee Arthroplasty.

Background And Objectives: Obstructive sleep apnea is associated with increased complication rates postoperatively. Current literature does not provide adequate guidance on management of these patients. This study used the STOP-Bang questionnaire to diagnose patients with possible obstructive sleep apnea (score ≥3).

Mycobacterium avium Complex Septic Arthritis Presenting as Osteonecrosis of the Femoral Head in a Patient With Systemic Lupus Erythematosus.

Mycobacterium avium complex is a rare cause of musculoskeletal infection, usually occurring in patients with compromised immune systems. Obtaining the diagnosis requires a high index of suspicion, and treatment can be delayed because of difficulty with isolating the organism. Treatment involves prolonged, targeted combination antibiotic therapy, and it is unclear whether eradication of the infection can occur in the presence of a foreign body, such as antibiotic spacers.

Duloxetine and Subacute Pain after Knee Arthroplasty when Added to a Multimodal Analgesic Regimen: A Randomized, Placebo-controlled, Triple-blinded Trial.

Background: Duloxetine is effective for chronic musculoskeletal and neuropathic pain, but there are insufficient data to recommend the use of antidepressants for postoperative pain. The authors hypothesized that administration of duloxetine for 15 days would reduce pain with ambulation at 2 weeks after total knee arthroplasty.

Methods: In this triple-blinded, randomized, placebo-controlled trial, patients received either duloxetine or placebo for 15 days, starting from the day of surgery.

Addition of Dexamethasone and Buprenorphine to Bupivacaine Sciatic Nerve Block: A Randomized Controlled Trial.

Background And Objectives: Sciatic nerve block provides analgesia after foot and ankle surgery, but block duration may be insufficient. We hypothesized that perineural dexamethasone and buprenorphine would reduce pain scores at 24 hours.

Methods: Ninety patients received ultrasound-guided sciatic (25 mL 0.

Periprosthetic joint infections treated with two-stage revision over 14 years: an evolving microbiology profile.

Late periprosthetic joint infection (PJI) occurs in 0.3%-1.7% of total hip arthroplasties (THAs) and 0.

Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement: a prospective, double-blind, randomized controlled trial.

Background: The perioperative inflammatory response as measured by elevated levels of interleukin-6 (IL-6) has been linked to acute respiratory distress syndrome, postoperative confusion, and fever. Because of the extent of surgery,patients undergoing bilateral total knee arthroplasty may be at high risk of complications. We had found a significant decrease in IL-6 in patients having bilateral total knee replacement who received two doses of 100 mg of hydrocortisone eight hours apart; however, by twenty-four hours, IL-6 levels were equal to those in the group that received a placebo.

Addition of pregabalin to multimodal analgesic therapy following ankle surgery: a randomized double-blind, placebo-controlled trial.

Background And Objectives: Pregabalin is often used as a perioperative analgesic adjunct; some studies show benefit, but others do not. Adverse effects, such as confusion and sedation, have been attributed to perioperative use of pregabalin. We tested the hypothesis that pregabalin, when used as part of a multimodal analgesic regimen, reduces the duration of moderate to severe pain in the first 24 hrs following foot or ankle surgery.

Use of low-dose steroids in decreasing cytokine release during bilateral total knee replacement.

Background: Interleukin 6 (IL-6), a marker of inflammation, is one of the major cytokines released during joint replacement. In the orthopedic patient population, high levels have been linked to many adverse effects including acute respiratory distress syndrome, postoperative mental status changes, and fever. We looked to assess the efficacy of low-dose steroids on the postinflammatory response as measured by IL-6 in patients undergoing bilateral total knee replacement (BTKR).

Pulmonary artery versus central venous catheter monitoring in the outcome of patients undergoing bilateral total knee replacement.

Bilateral total knee replacement (BTKR) has been associated with a higher incidence of fat embolism (FES) compared to single knee replacement. Consequently, intraoperative monitoring with a pulmonary artery catheter (PAC) has been recommended. This study compares clinical outcome in BTKR patients monitored with central venous pressure versus PAC.

Similar analgesic effect after popliteal fossa nerve blockade with 0.375% and 0.75% bupivacaine.

This study tested the hypothesis that increasing the concentration of bupivacaine from 0.375 to 0.75% would increase the duration of postoperative analgesia by 3 h.

Clonidine and analgesic duration after popliteal fossa nerve blockade: randomized, double-blind, placebo-controlled study.

Background: We tested the hypothesis that 100 microg clonidine added to 0.375% bupivacaine would prolong the duration of analgesia from popliteal fossa nerve blockade.

Methods: Ninety-nine patients scheduled for hospital admission after foot or ankle surgery entered this randomized, double-blind, placebo-controlled trial.

Pulmonary injury in patients undergoing complex spine surgery.

Background Context: Previous reports have shown that 15% of patients who undergo sequential anterior, then posterior, surgical corrections for spinal deformities demonstrate evidence of acute lung injury. By analyzing the bronchoalveolar lavage (BAL) fluid from these patients for evidence of acute inflammation, we might gain some insight into the etiology of this acute lung injury.

Purpose: To elucidate the etiology of acute lung injury after corrective surgery for adult spinal deformities.