Despite the widespread success of total hip arthroplasty (THA), postoperative pain management remains a concern. Opioids have classically been administered for pain relief after THA, but their side effect profile, in addition to the cognizance of the growing opioid epidemic, has incited a shift toward alternative pain modalities. Although the nonsteroidal anti-inflammatory drug (NSAID) diclofenac is a promising addition, its impact on immediate THA outcomes has not previously been investigated. Thus, in the present study, we evaluate the effects of adjunctive diclofenac on: 1) postoperative pain intensity, 2) opioid consumption, 3) discharge destination, 4) length of stay, and 5) patient satisfaction in primary THA patients. A retrospective review was performed to identify all patients who underwent primary THA by a single surgeon between May 1 and September 31, 2017. Patients were stratified into a study group (n=25), who were treated with postoperative diclofenac in addition to the standard pain control regimen, and a control group (n=88), who did not receive adjunctive diclofenac. Repeated-measures analysis of variance (ANOVA)/analysis of covariance (ANCOVA) and chi-square/logistic regression analysis were used for continuous and categorical variables, respectively. Patients receiving adjunctive diclofenac were more likely to be discharged home than to inpatient facilities (O.R. 4.02, p=0.049). In addition, patient satisfaction with respect to how well and how often pain was controlled (p= 0.0436 and p=0.0217, respectively) was significantly greater in the diclofenac group. Finally, patients who received diclofenac had lower opioid consumption on postoperative days one and two (−67.2 and −129 mg, respectively, p=0.001 for both). The rapid growth of THA as an outpatient procedure has intensified the urgency of improving postoperative pain management. The present study demonstrates that THA patients receiving adjunctive diclofenac were more likely to be discharged home, had reduced opioid consumption, and experienced greater satisfaction. This will, in turn, decrease complications and total hospital costs, leading to a more cost-effective pain control regimen. In order to further investigate the optimal regimen, future studies comprising larger cohort, as well as a comparison of diclofenac to other NSAIDs, are warranted

Introduction. Over the past few decades, opioid abuse has become a major threat to public health. In 2013 alone, enough opioid prescriptions were written in the United States for every American adult to have their own bottle of pills. Since then, opioid prescribing rates and opioid related deaths have continued to grow, with over 46 people dying on average each day from prescription opioid overdoses in 2016. Orthopaedic surgeons are among the top 5 specialties in the number of opioid prescriptions written. For many common surgeries, such as total knee arthroplasty (TKA), post-discharge prescriptions are based on prescriber habits and opinion. There exists limited data-driven protocols to guide post-operative opioid prescribing practices. The purpose of this prospective study was to determine the average postoperative opioid consumption in patients undergoing primary TKA using a novel mobile text messaging platform. We hypothesized that majority of patients undergoing TKA do not properly dispose of left over pills after surgery. Methods. 95 patients undergoing primary unilateral TKA with one of nine arthroplasty surgeons at a single orthopaedic specialty hospital were prospectively enrolled. Daily pain levels and opioid consumption, and quantity and disposal patterns for left over medications were collected for six weeks following surgery using a novel mobile phone text messaging system. This system automatically queried patients twice a day, storing responses on a secure third-party host that investigators monitored and used to generate data reports in real-time. Results. Of the 95 patients enrolled, 1 was excluded for undergoing a secondary procedure in the acute postoperative data collection period. Of the remaining 94 patients, 88 (93.6%) completed the daily SMS surveys and were included in analysis. Average age was 62.0 ± 7.1 years, BMI 31.1 ± 6.2, and length of hospital stay 2.6 ± 1.2 days. The average oral morphine equivalents (OME) consumed during the 6 weeks post-surgery were 617.3 ± 350.26 mg, which corresponds to a mean consumption of 82 oxycodone 5 mg tablets per patient. For the 55(58.5%) of patients who had stopped taking opioids within 6 weeks of surgery, there were on average 196.2 mg OME left over, the equivalent of 26 oxycodone 5 mg tablets; 20% of those who stopped taking opioids had at least 367.5 mg OME left over, the equivalent of at least 49 oxycodone 5 mg tablets. Only 26.5% of patients with left over pills described an appropriate method of disposal of left over medications, with most patients storing left over pills in their homes. Conclusion. This prospectively collected data provides a benchmark for average opioid consumption after uncomplicated primary unilateral TKA. Many patients are prescribed more opioids than they require, and left-over medication is infrequently disposed of appropriately, which increases the risk for illicit diversion. Prospective collection of patient reported opioid consumption has tremendous value in the development of national postoperative guideline protocols while informing further research and strategies aimed to reduce opioid use and misuse and in predicting patient characteristics associated with increased opioid consumption after surgery

Introduction. The use of intraoperative liposomal bupivacaine (LB) peri-articular injection has been highly debated for total knee arthroplasty (TKA). We evaluated the effect of an institutional-wide discontinuation of intraoperative LB on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Material and Methods. Between July 1, 2019 and November 30, 2019, an institutional policy discontinued use of intraoperative LB, while the volume of non-LB with epinephrine was increased from 40-ml to 60-ml. A historical cohort was derived from patients undergoing TKA between January 1, 2019 and June 30, 2019. All patients received the same opioid sparing protocol, minimizing variability in prescribing habits. No adductor canal blocks/pumps were utilized. Nursing documented verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Opiate administration events were derived as Morphine Milligram Equivalences (MMEs) per patient per 24-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) tool was utilized. All time events were calculated relative to TKA completion instant. Results. 789 primary TKAs did not receive intraoperative LB, while 888 patients acted as controls. Age was significantly greater in patients that did not receive intraoperative liposomal bupivacaine (66.80±8.97 vs 65.57±9.46; p<.01). Gender, BMI, ASA physical status score, race, smoking status, marital status, surgical time, length of stay and discharge disposition were similar between the two groups (p>.05). Compared to historical controls, discontinuation of LB demonstrated no significant difference in postoperative inpatient VRS pain scores up to 72 hours (p>.05), opioid administration up to 96 hours (p>.05), or AM-PAC scores within the first 24 hours (p>.05). Discussion. Subjective pain scores, opioid consumption, and functional scores were unchanged in the early postoperative period following the discontinuation of intraoperative liposomal delivery of bupivacaine in TKA

Introduction. Postoperative pain is a concern for patients undergoing Total Knee Arthroplasty (TKA) and plays an important role in opioid consumption, length of stay, and postoperative function. The purpose of this study was to compare outcomes in patients who underwent primary TKA comparing femoral and sciatic (F+S) combination motor nerve block versus an adductor canal and the interspace between the popliteal artery and the capsule of the posterior knee (ACB+IPACK) combination sensory nerve block. Methods. 100 consecutive primary TKA cases performed by a single surgeon using the same surgical approach and implant design were reviewed. The first 50 patients received F+S nerve blocks and the second 50 received ACB+IPACK blocks preoperatively. Both groups also received total intravenous anesthesia (TIVA). Differences in opioid requirements, length of stay (LOS), distance walked, Western Ontario & McMasters University Osteoarthritis Index (WOMAC), Knee Society (KSS) function scores, Visual Analog Scores (VAS) for pain at rest and with activity, and postoperative complications were analyzed. There were no differences in the groups with respect to age, sex or BMI. Results. 62% of patients were discharged on postoperative day #1 in the ACB+IPACK group compared to 14% in the F+S group (p<.0001). The ACB+IPACK patients had a shorter LOS (average 1.48 days versus 2.02 days, p<0.0001), ambulated further on postop day #0 (average 21.4 feet versus 5.3 feet, p<0.0001), required less narcotics the day after surgery (average 15.7 versus 24.0 morphine equivalents p<0.0001) and at 2 weeks postoperative (average 6.2 versus 9.3 morphine equivalents, p=0.025), and required less manipulations under anesthesia (1 versus 5, p=0.204). WOMAC, KSS, and VAS scores were not significantly different. Discussion. The use of combination adductor canal and IPACK sensory blocks demonstrated improved early ambulation with decreased opioid use, length of stay, and postoperative manipulations. This study suggests that the use of combination sensory adductor canal and IPACK nerve blocks are superior to motor nerve blocks in patients undergoing primary TKA

The current study aims to find the role of Enhance Recovery Pathway (ERP) as a multidisciplinary approach aimed to expedite rapid recovery, reduce LOS, and minimize morbidity associated with Non Fusion Anterior Scoliosis Correction (NFASC) surgery. A retrospective analysis of 35 AIS patients who underwent NFASC with Lenke 1 and Lenke 5 curves with a minimum of 1 year of follow-up was done. Patient demographics, surgical details, postoperative analgesia, mobilization, length of stay (LOS), patient satisfaction survey score with respect to information and care, and 90 days complications were collected. The cohort included 34 females and 1 male with a mean age of 15.2 years at the time of surgery. There were 16 Lenke 1 and 19 Lenke 5 in the study. Mean preoperative major thoracic and thoracolumbar/lumbar Cobb's angle were 52˚±7.6˚ and 51˚±4.5˚ respectively. Average blood loss and surgical time were 102 ±6.4 ml and 168 ± 10.2 mins respectively. Average time to commencing solid food was 6.5±1.5 hrs. Average time to mobilization following surgery was 15.5± 4.3 hrs. The average duration to the stopping of the epidural was 42.5±3.5 hrs. The average dose of opioid consumption intraoperatively was 600.5±100.5 mcg of fentanyl i.v. and 12.5±4.5 mg morphine i.v. Postoperatively opioids were administered via an epidural catheter at a dose of 2 mg of morphine every 24 hours up to 2 days and an infusion of 2mcg/hr of fentanyl along with 0.12-0.15% ropivacaine. The average duration to transition to oral analgesia was 55.5±8.5 hrs .20 patients had urinary catheter and the average time to removal of the catheter was 17.5±1.4 hrs. 25 patients had a chest tube and the average time to remove of chest tube was 25.5±3.2 hrs. The average length of hospital stay was 3.1±0.5 days. No patient had postoperative ileus or requirement of blood transfusion or any other complications. No correlation was found between LOS and initial cobb angle. The application of ERP in AIS patients undergoing NFASC results in reduced LOS and indirectly the cost, reduced post-operative opioid use, and overall improve patient satisfaction score

Summary

Narcotic administration within the inpatient setting is highly variable any may benefit from the implementation of standardized multi-modal pain management protocols.

Summary

Despite adoption of robust clinical pathways, narcotic administration within the inpatient setting is highly variable and may benefit from the implementation of standardized multi-modal pain management protocols.

Proponents of the direct anterior approach (DAA) for hip arthroplasty (THA) claim lower postoperative pain compared to the posterolateral approach (PA); however, whether that theoretical advantage results in lower opioid consumption is unclear. We sought to investigate the relationship between the DAA and PA on total 90-day predicted opioid consumption in a large cohort. Retrospective analysis identified 2,304 DAA and 6,288 PA primary THAs in patients >18 years old from February 2019 to April 2022. Ninety-day postoperative total morphine milligram equivalent (MME); in-hospital administration, discharge prescriptions, and refills within 90 days were compared between DAA and PA cohorts. Nearest-neighbor matching was performed controlling for age, sex, BMI, ASA, and periarticular injection to evaluate opioid consumption patterns for DAA and PA. Quantile regression was employed to predict the median (50th percentile) MME prescribed by surgical approach. After matching, DAA and PA demonstrated similar median total 90-day prescribed MME (p = 0.008). After adjusting for patient and surgical factors, quantile regression predicted a similar median total 90-day prescribed MME for DAA and PA (243.5 versus 242.7; p = 0.78). While approach did not demonstrate a significant relationship for predicted 90-day MME, other factors including age, sex, BMI, length of stay, peripheral anesthesia, periarticular injection, and white or Caucasian race demonstrated a significant relationship with predicted 90-day MME (p <0.0001). While we identified several risk factors for increased in-hospital and 90-day post-operative opioid consumption, a comparison between DAA and PA did not demonstrate significantly different opioid prescribing patterns

Abstract. Introduction. To compare the efficacy of adductor canal blocks (ACB) and periarticular anesthetic injections (PAI) with bupivacaine in total knee arthroplasty. Methods. 90 patients undergoing primary total knee arthroplasty under spinal anesthesia were randomized to 1 of 3 groups: ACB alone (15 mL of 0.5% bupivacaine), PAI alone (50 mL of 0.25% bupivacaine with epinephrine) and ACB + PAI. Primary outcome in this study was the visual analog scale (VAS) pain score in the immediate postoperative period. Secondary outcomes included postoperative opioid use, activity level during physiotheraphy, length of hospital stay and ROM. Results. Mean VAS pain score was significantly higher with ACB alone, compared with the score after use of ACB+PAI, on POD1 and POD3. Total opioid consumption through POD3 was significantly higher when ACB alone had been used compared with PAI alone and ACB+PAI. Opioid consumption in the ACB-alone group was significantly higher than that in the ACB + PAI group on POD2 and POD3 and significantly higher than that in the PAI alone group on POD2. There was no significant difference in opioid consumption between the patients treated with PAI alone and those who received ACB + PAI. The activity level during physiotherapy on POD0 was significantly lower after use of ACB alone than after use of PAI alone or ACB + PAI. Conclusion. Higher pain scores after total knee arthroplasty done with an ACB and without PAI, suggesting that ACB alone is inferior for perioperative pain control. There were no significant differences between ACB alone, PAI alone and ACB + PAI inparameters measured

Introduction. Prosthetic designs that use porous metals possess an extremely high surface area and through capillary effect may potentially ‘absorb’ and later elute analgesic solution, serving as a surgical site drug depot. This study aimed to determine if a highly porous acetabular component submerged in an aqueous-based analgesic solution prior to implantation reduced postoperative pain scores and opioid consumption in the early post-operative period. Methods. Using our IRB approved database, 200 consecutive opioid naïve primary THA patients operated on by a single surgeon at two institutions using the same acetabular component were identified. 100 patients had a standard volume/concentration of an analgesic cocktail soft-tissue injection at closure (control). 100 patients had their acetabular components submerged into the same cocktail prior to implantation (treatment) and the balance of the volume injected. Postoperative protocols were otherwise identical. Groups were compared for visual analog pain scores (VAS), opioid consumption, 1-year radiographic findings and surgical revision rates. Results. VAS were lower in the treatment group at 6hrs (2.35±1.8 v. 3.31±2.3, p<0.01), 12hrs (2.00±1.6 v. 3.61±2.3, p<0.01), 18hrs (2.36±1.7 v. 3.44±1.9, p<0.01), and 24 hrs (2.20±1.6 v. 3.82±1.9, p<0.01). Opioid consumption was lower in the treatment group at all time point in the first 24 hours and significantly lower in the first 6 hours (7.18±9.42 MME v. 10.76±11.37 MME, p<0.05) and between 12 and 24 hours postoperatively (10.43±15.94 MME v. 17.08±22.75 MME, p<0.05). The total MME administered to the treatment group was significantly lower than the control group (48.3±59.7 MME vs. 76.1±78.6 MME, respectively; p<0.01). At one-year, there was no radiographic evidence of periacetabular lucencies and no revisions for loosening. Conclusion. The use of a highly porous component commonly used in THA as a potential analgesic drug depot in combination with soft-tissue injections may reduce postoperative pain scores and opioid consumption compared to soft-tissue injections alone

Introduction. Opioids are an integral part of pain management following total joint replacement procedures; however, to date, no evidence-based guidelines which regulate opioid prescribing practices exist. In order to determine an appropriate number of opioids required to control pain for post-arthroplasty patients, it is important to understand why patients are using them. We sought to identify the causes of pain which necessitated opioid consumption for patients following total knee (TKA) and total hip (THA) arthroplasty. Methods. The study cohort consisted of 55 patients (29 females, 26 males) who underwent either primary unilateral TKA (n=28) or THA (n=27). Prior to discharge, patients were provided with a pain diary in which to record details regarding the type of pain medication used, the time of use, pain score at the time of use, and the specific reason for use. Subjects returned the completed logs once they ceased opioid use post-operatively. Based on responses, we categorized reasons for use into either Activity, which was further classified into ADL and Exercise, or Rest, which was further classified into Sleeping, Sitting, and Laying Down. Average and frequency of opioid consumption was calculated for each category, along with the pain score at the time of use for each category. All dependent variables were compared between TKA and THA patients using separate independent samples t-tests or Chi-square tests. Results. Overall, 13 patients did not consume any opioids during the post-operative period, and data regarding the specific reason for opioid use were available for 33 patients (16 THA, 17 TKA). For THA patients, the most common reason for opioid consumption was Sleeping (47%), followed by Exercise (20%), Sitting (16%), ADL (10%), and Laying Down (7%). Conversely, TKA patients reported the most frequent opioid use for pain during Exercise (32%), Sitting (28%), ADL (14%), Sleeping (14%), and Laying Down (12%). The frequency of consumption was greater for THA patients during Sleeping (p<0.001), but reduced during Exercise (P<0.001) and Sitting (p<0.001) compared to TKA patients. The average number of opioid pills consumed during ADL (p=0.05) and Exercise (p=0.02) was greater for TKA patients compared to THA. Pain scores reported during Exercise (p=0.33) and Sleeping (p=0.08) were similar between groups; however, TKA patients reported higher pain scores during Resting (p=0.047). Conclusion. Our results demonstrate that the causes associated with opioid consumption following arthroplasty procedures differ between TKA and THA patients. Opioid use was most common at night during sleeping for THA patients, while TKA patients reported greater usage during the day while exercising or sitting. Our data can be used to counsel patients regarding pain expectations following TKA or THA and create standardized prescribing and tapering guidelines to effectively manage pain while limiting opioid use

Orthopaedic surgeons prescribe more opioids than any other surgical speciality. Opioids remain the analgesic of choice following arthroscopic knee and shoulder surgery. There is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients’ pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. The objective of the current randomized controlled trial (RCT) was to evaluate the efficacy of a multi-modal, opioid-sparing approach to postoperative pain management in patients undergoing arthroscopic shoulder and knee surgery. The NO PAin trial is a pragmatic, definitive RCT (NCT04566250) enrolling 200 adult patients undergoing outpatient shoulder or knee arthroscopy. Patients are randomly assigned in a 1:1 ratio to an opioid-sparing group or standard of care. The opioid-sparing group receives a three-pronged prescription package consisting of 1) a non-opioid prescription: naproxen, acetaminophen and pantoprazole, 2) a limited opioid “rescue prescription” of hydromorphone, and 3) a patient education infographic. The control group is the current standard of care as per the treating surgeon, which consists of an opioid analgesic. The primary outcome of interest is oral morphine equivalent (OME) consumption up to 6 weeks postoperatively. The secondary outcomes are postoperative pain scores, patient satisfaction, quantity of OMEs prescribed and number of opioid refills. Patients are followed at both 2 and 6 weeks postoperatively. Data analysts and outcome assessors are blinded to the treatment groups. As of December 1, 2021 we have enrolled 166 patients, reaching 83% of target enrolment. Based on the current recruitment rate, we anticipate that enrolment will be completed by the end of January 2022 with final follow-up and study close out completed by March of 2022. The final results will be released at the Canadian Orthopaedic Association Meeting in June 2022 and be presented as follows. The mean difference in OME consumption was XX (95%CI: YY-YY, p=X). The mean difference in OMEs prescribed was XX (95%CI: YY-YY, p=X). The mean difference in Visual Analogue Pain Scores (VAS) and patient satisfaction are XX (95%CI: YY-YY, p=X). The absolute difference in opioid refills was XX (95%CI: YY-YY, p=X). The results of the current study will demonstrate whether an opioid sparing approach to postoperative outpatient pain management is effective at reducing opioid consumption while adequately addressing postoperative pain in patients undergoing outpatient shoulder and knee arthroscopy. This study is novel in the field of arthroscopic surgery, and its results will help to guide appropriate postoperative analgesic management following these widely performed procedures

Orthopaedic surgeons prescribe more opioids than any other surgical speciality. Opioids remain the analgesic of choice following arthroscopic knee and shoulder surgery. There is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients’ pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. The objective of the current randomized controlled trial (RCT) was to evaluate the efficacy of a multi-modal, opioid-sparing approach to postoperative pain management in patients undergoing arthroscopic shoulder and knee surgery. The NO PAin trial is a pragmatic, definitive RCT (NCT04566250) enrolling 200 adult patients undergoing outpatient shoulder or knee arthroscopy. Patients are randomly assigned in a 1:1 ratio to an opioid-sparing group or standard of care. The opioid-sparing group receives a three-pronged prescription package consisting of 1) a non-opioid prescription: naproxen, acetaminophen and pantoprazole, 2) a limited opioid “rescue prescription” of hydromorphone, and 3) a patient education infographic. The control group is the current standard of care as per the treating surgeon, which consists of an opioid analgesic. The primary outcome of interest is oral morphine equivalent (OME) consumption up to 6 weeks postoperatively. The secondary outcomes are postoperative pain scores, patient satisfaction, quantity of OMEs prescribed and number of opioid refills. Patients are followed at both 2 and 6 weeks postoperatively. Data analysts and outcome assessors are blinded to the treatment groups. As of December 1, 2021 we have enrolled 166 patients, reaching 83% of target enrolment. Based on the current recruitment rate, we anticipate that enrolment will be completed by the end of January 2022 with final follow-up and study close out completed by March of 2022. The final results will be released at the Canadian Orthopaedic Association Meeting in June 2022 and be presented as follows. The mean difference in OME consumption was XX (95%CI: YY-YY, p=X). The mean difference in OMEs prescribed was XX (95%CI: YY-YY, p=X). The mean difference in Visual Analogue Pain Scores (VAS) and patient satisfaction are XX (95%CI: YY-YY, p=X). The absolute difference in opioid refills was XX (95%CI: YY-YY, p=X). The results of the current study will demonstrate whether an opioid sparing approach to postoperative outpatient pain management is effective at reducing opioid consumption while adequately addressing postoperative pain in patients undergoing outpatient shoulder and knee arthroscopy. This study is novel in the field of arthroscopic surgery, and its results will help to guide appropriate postoperative analgesic management following these widely performed procedures

Introduction. Tourniquet use in total knee arthroplasty (TKA) remains controversial and few reports exist using contemporary pain protocols and tranexamic acid (TXA). This study aimed to examine whether a modern TKA protocol without a tourniquet results in less blood loss, patient-reported pain, and opioid consumption compared to TKAs with a tourniquet. Methods. A retrospective study was performed on 210 consecutive primary cemented TKAs using computer-assisted navigation with or without tourniquet. The tourniquet was inflated the entire procedure or not at all, and sterile CO2 gas was used to maximise cement interdigitation in non-tourniquet knees. All patients received identical implants and underwent the same TKA perioperative protocols. Standardised inpatient pain level targets were utilised and medication titrated to control postoperative pain. Pain on a 10 point scale in the first 24 hours after surgery and blood loss (preoperative to postoperative day 1 decline in hemoglobin, total blood loss in liters, drain output in milliliters, and drain output per hour) were analyzed relative to tourniquet use. Results. After exclusions for confounds, 184 consecutive TKAs (93 tourniquet; 91 tourniquetless) were analyzed. Age (p = 0.561) and BMI (p = 0.580) did not differ between the two groups. By chance, there were significantly more females in the tourniquet group (55.9%) compared to the no tourniquet group (44.1%) (p = 0.019). Consequently, outcome analyses were performed separately for females and males. Median pain in the first 24 hours was significantly lower for women without a tourniquet (1.9 vs. 2.7, p = 0.002). This corresponded to significantly less opioid consumption in the first 24 hours among women without tourniquets (18.8 vs. 42.8 Me, p < 0.0001). Neither pain nor opioid consumption in the first 24 hours differed based on tourniquet use in men (p ≥ 0.114). Not surprisingly, significantly more blood loss was observed on all four metrics in tourniquetless knees for both women (p ≤ 0.040) and men (p ≤ 0.020). Discussion. In contemporary TKA using multi-modal pain protocols and TXA, not using a tourniquet resulted in less pain and lower narcotic consumption in the first 24 hours after surgery for women, but not for men. It is possible that women may be more affected by tourniquet-induced ischemia in the early postoperative period. These results are timely with current national initiatives to minimise perioperative opioid consumption

Introduction. Tourniquet use in total knee arthroplasty (TKA) remains controversial and few reports exist using contemporary pain protocols and tranexamic acid (TXA). This study aimed to examine whether a modern TKA protocol without a tourniquet results in less blood loss, patient-reported pain, and opioid consumption compared to TKAs with a tourniquet. Methods. A retrospective study was performed on 210 consecutive primary cemented TKAs using computer-assisted navigation with or without tourniquet. The tourniquet was inflated the entire procedure or not at all, and sterile CO2 gas was used to maximise cement interdigitation in non-tourniquet knees. All patients received identical implants and underwent the same TKA peri-operative protocols. Standardised inpatient pain level targets were utilised and medication titrated to control post-operative pain. Pain on a 10 point scale in the first 24 hours after surgery and blood loss (pre-operative to post-operative day 1 decline in hemoglobin, total blood loss in liters, drain output in milliliters, and drain output per hour) were analyzed relative to tourniquet use. Results. After exclusions for confounds, 184 consecutive TKAs (93 tourniquet; 91 tourniquetless) were analyzed. Age (p = 0.561) and BMI (p = 0.580) did not differ between the two groups. By chance, there were significantly more females in the tourniquet group (55.9%) compared to the no tourniquet group (44.1%) (p = 0.019). Consequently, outcome analyses were performed separately for females and males. Median pain in the first 24 hours was significantly lower for women without a tourniquet (1.9 vs. 2.7, p = 0.002). This corresponded to significantly less opioid consumption in the first 24 hours among women without tourniquets (18.8 vs. 42.8 Me, p < 0.0001). Neither pain nor opioid consumption in the first 24 hours differed based on tourniquet use in men (p ≥ 0.114). Not surprisingly, significantly more blood loss was observed on all four metrics in tourniquetless knees for both women (p ≤ 0.040) and men (p ≤ 0.020). Discussion. In contemporary TKA using multi-modal pain protocols and TXA, not using a tourniquet resulted in less pain and lower narcotic consumption in the first 24 hours after surgery for women, but not for men. It is possible that women may be more effected by tourniquet-induced ischemia in the early post-operative period. These results are timely with current national initiatives to minimise peri-operative opioid consumption

We performed a randomized feasibility trial to examine the impact of preoperative femoral nerve block (FNB) on elderly patients with hip fractures, including those with mild to moderate cognitive impairment. We evaluated the impact of preoperative FNB on the following outcomes within 5 days of surgical fixation: 1. Pain levels, 2. Total narcotic consumption, 3. Postoperative mobilization. Randomized allocation of 73 patients in a 2:1 intervention:control ratio. To allow comparison between the 2 groups as well as sub- analysis of the intervention group to examine treatment fidelity (i.e. the ability to deliver the intervention as planned). Inclusion criteria: Patient age≥ 65 years admitted with a low energy hip fracture, ambulatory preinjury, Mini Mental State Exam MMSE score≥13 (moderate dementia), Able to provide direct or proxy consent. Exclusion criteria: Admission ≥ 30 hours after injury, prior regular use of opiates. Potential participants were identified and either participants or proxy respondents provided signed informed consent. Participants allocated to the intervention group received a FNB administered by the UAH acute pain service (APS) within 20 hours of admission to hospital in addition to the usual care. Participants in the control group received usual care. Participants were followed for 5 days postoperatively with daily assessment of pain, narcotic consumption, delirium and mobility. Main outcome measure: (1) Pain at rest and activity (2) Preoperative and postoperative opioid consumption, (3) Mobilization in POD#1. Overall, 73 participants were enrolled (23 Control: 50 FNB). The FNB group was slightly older (mean [SD] 80.1 [8.7] vs. 76.2 [9.2], p=0.09) and had more males (21 [42%] vs. 5 [22%], p=0.09) than the Control group. The mean MMSE score for both groups was >24 (p=0.35 for group comparison), suggesting minimal cognitive impairment of participants. The FNB group reported significantly less pain at rest and activity than the control group over time (p < 0 .001 for both). Opioid consumption were non-significantly higher and more variable in the control group preoperatively (Median [25, 75 quartile] 10.6 [0, 398] vs 7.5 [0, 125], p=0.26) and postoperatively (13.1 [0, 950] vs 10 [0, 260], p=0.31). 41 (85%) of FNB participants mobilized on day 1 vs. 16 (73%) of control participants (p=0.21). Preoperative FNB significantly reduced pain. Opioid consumption was not significantly different, but more variable in the control group. Although not significant, more FNB patients successfully mobilized on day 1 postoperatively. Participants with cognitive impairment were not enrolled due to difficulty in obtaining proxy consent. A definitive randomized trial would be feasible and add valuable information about pain management following hip fracture

Introduction. Enhanced Recovery After Surgery (ERAS) is a multi-disciplinary approach for establishing procedure–specific, evidence-based perioperative protocols to optimize patient outcomes. ERAS evidence is predominantly for non-orthopaedic procedures. We review the impact of ERAS protocol implementation on total joint arthroplasty (TJA) outcomes at our institution. Methods. All primary total hip and knee arthroplasties performed one year before and after ERAS implementation were identified by current procedural terminology code. Length of stay (LOS), disposition, readmission and opioid usage were analyzed before and after ERAS implementation and statistically analyzed with student t-test and chi-square test. Results. 2105 total patients were identified (967 THA, 494 pre-ERAS and 473 post-ERAS;1138 TKA, 575 pre-ERAS and 563 post-ERAS). TKA. After ERAS implementation, opioid consumption decreased for hospital day one (45.5MME to 36.2MME; p=0.000) and overall hospitalization (101.9MME to 83.9MME; p =0.000). Average LOS decreased (73.28hrs to 66.44hrs; p=0.000), blood transfusion rate trended down (3.3% to 1.95%; p=0.155), and disposition to home over skilled nursing facility increased (57.8% to 71.6%; p=0.000). Unplanned return-to-hospital encounters were unchanged (13.22% to 12.79%; p=0.8504). 30-day and 90-day readmission rates decreased (7.30% to 3.02%; p=0.0020 and 8.5% to 4.8%; p=0.0185, respectively). THA. After ERAS implementation, opioid consumption decreased for hospital day one (49.5MME to 35.4MME; p=0.000) and overall hospitalization (79.5MME to 59.5MME; p=0.000). Average LOS decreased (57.84hrs to 51.87hrs; p=0.011), blood transfusion rate was unchanged (4.25% to 3.81%; p=0.725), and disposition to home over skilled nursing facility increased (80.4% to 82.5%; p= 0.022). Unplanned return-to-hospital encounters were unchanged (8.51% to 8.88%; p=0.8486). Readmission trended up during postoperative days 0–30 and trended down during postoperative days 31–90. (1.42% to 2.96%; p=0.1074) and (1.21% to 0.85%; p=0.5748), respectively. Conclusion. ERAS protocols reduce postoperative opioid consumption, decrease hospital LOS, and increase patient disposition to home without adversely affecting short-term readmission rates

Dexmedetomidine, an alpha 2 agonist, has been approved for providing sedation in the intensive care unit. Along with sedative properties, it has analgesic activity through its highly selective action on alpha 2 receptors. Recent studies have examined the use of dexmedetomidine as an adjuvant to prolong the duration of peripheral nerve blocks. Studies showing effectiveness of dexmedetomidine for adductor canal block in knee surgery are small. Also, its effectiveness has not been compared to Epinephrine which is a strong alpha and beta receptor agonist. In a previous study, we showed that motor sparing knee blocks significantly increased the duration of analgesia compared with periarticular knee infiltration using local anesthetic mixture containing Epinephrine following total knee arthroplasty (TKA). In this study, we compared two local anesthetic mixtures: one containing Dexmedetomidine and the other Epinephrine for prolongation of motor sparing knee block in primary TKA patients. After local ethics board approval and gaining Notice of Compliance (NOC) from Health Canada for use of Dexmedetomidine perineurally, 70 patients between the ages 18 – 95 of ASA class I to III undergoing unilateral primary total knee arthroplasty were enrolled. Motor sparing knee block − 1) Adductor canal continuous catheter 2) Single shot Lateral Femoral Cutaneous Nerve block 3) Single shot posterior knee infiltration was performed in all patients using 60 ml mixture of 0.5% Ropivacaine, 10 mg Morphine, 30 mg Ketorolac. Patients randomized into the Dexmedetomidine group (D) received, in addition to the mixture, 1mcg/kg Dexmedetomidine and the Epinephrine (E) group received 200mcg in the mixture. The primary outcome was time to first rescue analgesia as a surrogate for duration of analgesia and secondary outcomes were NRS pain scores up to 24 hours and opioid consumption. The time to first rescue analgesia was not significantly different between Epinephrine and dexmedetomidine groups, Mean and SD 18.45 ± 12.98 hours vs 16.63 ± 11.80 hours with a mean difference of 1.82 hours (95% CI −4.54 to 8.18 hours) and p value of 0.57. Pain scores at 4, 6, 12, 18 and 24 hours were comparable between groups. Mean NRS pain scores Epinephrine vs Dexmedetomidine groups were 1.03 vs 0.80 at 4 hours, 1.48 vs 3.03 at 6 hours, 3.97 vs 4.93 at 12 hours, 5.31 vs 6.18 and 6.59 v 6.12 at 24 hours. Opioid consumption was also not statistically significant between both groups at 6, 12 18, 24 hours (p values 0.18, 0.88, 0.09, 0.64 respectively). Dexmedetomidine does not prolong the duration of knee motor sparing blocks when compared to Epinephrine for total knee arthroplasty. Pain scores and opioid consumption was also comparable in both groups. Further studies using higher dose of dexmedetomidine are warranted

Introduction. Even as the outcomes of primary total knee arthroplasty (TKA) continue to improve, there remain increasing concerns about pain control after surgery and prolonged narcotic use. Cryoneurolysis has been demonstrated to reduce osteoarthritis knee pain for up to 90 days. We hypothesized that postoperative narcotic use could be reduced following preoperative cryoneurolysis of the superficial genicular nerves. Methods. Primary TKA patients were randomized into either a control or cryoneurolysis treatment group. Both followed the same preoperative, intraoperative, and postoperative pain management protocol, except the treatment group had cryoneurolysis of their superficial genicular nerves 3–7 days prior to surgery. All patients were prescribed 40 narcotic pills at discharge and pills were counted at 72 hours and at 2,6, and 12 weeks postoperatively. The primary endpoint was daily morphine equivalent (DME) based on pill count and secondary endpoints were changes in pain and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, Jr.) scores. Results. Per-protocol results demonstrated that the DME for the treatment group was significantly lower at 72 hours (10.9 mg vs. 14.9 mg, p=0.0389), 6 weeks (4.2 mg vs. 5.9 mg, p=0.0186) and 12 weeks (2.4 mg vs 3.4 mg p=0.0234). Overall, there was a 29% reduction in the DMEs over the entire 12-week postoperative period. Only 14% of the treatment group consumed opioids past 6 weeks compared to 44% of the control group (p=0.0005). The treatment group demonstrated a greater reduction in pain scores from baseline at 72 hours and 12 weeks. The treatment group also showed significant improvements in KOOS Jr. scores compared to the control group at all timepoints. Conclusions. The results demonstrate that preoperative cryoneurolysis can reduce opioid consumption after TKA. The early cessation of opioid consumption is especially encouraging given the association of prolonged narcotic use with increased complications following surgery. Preoperative cryoneurolysis should be considered as part of a multimodal protocol to reduce opioid consumption and pain and improve function after TKA. For figures, tables, or references, please contact authors directly

Introduction. Day stay surgery for anterior cruciate ligament (ACL) reconstructions is an increasingly common practice and has driven clinicians to come up with postoperative pain regimes that allow same day mobilisation and a safe and timely discharge. There is a paucity of literature surrounding the use of intraosseous (IO) ropivacaine used as a Bier's block to provide both intraoperative and postoperative analgesia in lower limb surgery. Methods. This patient blinded, pilot study randomised 15 patients undergoing ACL reconstruction to receive either IO ropivacaine 1.5 or 2.0 mg/kg; or 300 mg of ropivacaine as local infiltration (standard of care). Toxic plasma levels of ropivacaine have been defined in the literature and therefore the primary outcome for this study was arterial plasma concentration of ropivacaine as a means to determine its safety profile. Samples were taken via an arterial line at prespecified times after tourniquet deflation. Secondary outcomes that we were interested in included immediate postoperative pain scores using the visual analogue scale (VAS) and perioperative opioid equivalent consumption. Results. Participants had a mean age of 27.8 (SD 9.2) years and 87% (13/15) were male. All patients in the intervention group receiving IO ropivacaine had plasma concentrations well below the threshold for central nervous system (CNS) toxicity (0.60 µg/ml). The highest plasma concentration was achieved in the intervention group receiving 1.5 mg/kg dose of ropivacaine reaching 3.59 mg/ml. This would equate to 0.22 µg/ml of free plasma ropivacaine. There were no differences across the three groups regarding pain scores or perioperative opioid consumption. Conclusions. This study demonstrates that IO administration of 0.2% ropivacaine is both safe and effective in reducing perioperative pain in patients undergoing ACL reconstruction. There may be scope to increase the IO dose further or utilise other analgesics via the IO regional route to improve perioperative pain relief