Pain management in spine surgery can be challenging. Cannabis might be an interesting choice for analgesia while avoiding some side effects of opioids. Recent work has reported on the potential benefits of cannabinoids for multimodal pain control, but very few studies focus on spinal surgery patients. This study aims to examine demographic and health status differences between patients who report the use of (1) cannabis, (2) narcotics, (3) cannabis and narcotics or (4) no cannabis/narcotic use. Retrospective cohort study of thoracolumbar patients enrolled in the CSORN registry after legalization of cannabis in Canada. Variables included: age, sex, modified Oswestry Disability Index (mODI), Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness leg sensation, SF-12 Quality of Life- Mental Health Component (MCS), Patient Health Questionnaire (PHQ-9), and general health state. An ANCOVA with pathology as the covariate and post-hoc analysis was run. The majority of the 704 patients enrolled (mean age: 59; female: 46.9%) were non-users (41.8%). More patients reported narcotic-use than cannabis-use (29.7% vs 12.9%) with 13.4% stating concurrent-use. MCS scores were significantly lower for patients with concurrent-use compared to no-use (mean of 39.95 vs 47.98, p=0.001) or cannabis-use (mean=45.66, p=0.043). The narcotic-use cohort had significantly worse MCS scores (mean=41.37, p=0.001) than no-use. Patients reporting no-use and cannabis-use (mean 41.39 vs 42.94) had significantly lower ODI scores than narcotic-use (mean=54.91, p=0.001) and concurrent-use (mean=50.80, p=0.001). Lower NRS-Leg pain was reported in cannabis-use (mean=5.72) compared to narcotic-use (mean=7.19) and concurrent-use (mean=7.03, p=0.001). No-use (mean=6.31) had significantly lower NRS-Leg pain than narcotic-use (p=0.011), and significantly lower NRS-back pain (mean=6.17) than narcotic-use (mean=7.16, p=0.001) and concurrent-use (mean=7.15, p=0.012). Cannabis-use reported significantly lower tingling/numbness leg scores (mean=4.85) than no-use (mean=6.14, p=0.022), narcotic-use (mean=6.67, p=0.001) and concurrent-use (mean=6.50, p=0.01). PHQ-9 scores were significantly lower for the no-use (mean=6.99) and cannabis-use (mean=8.10) than narcotic-use (mean=10.65) and concurrent-use (mean=11.93) cohorts. Narcotic-use reported a significantly lower rating of their overall health state (mean=50.03) than cannabis-use (mean=60.50, p=0.011) and no-use (mean=61.89, p=0.001). Patients with pre-operative narcotic-use or concurrent use of narcotics and cannabis experienced higher levels of disability, pain and depressive symptoms and worse mental health functioning compared to patients with no cannabis/narcotic use and cannabis only use. To the best of our knowledge, this is the first and largest study to examine the use of cannabis amongst Canadian patients with spinal pathology. This observational study lays the groundwork to better understand the potential benefits of adding cannabinoids to control pain in patients waiting for spine surgery. This will allow to refine recommendations about cannabis use for these patients

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach. Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption. During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively. For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control

Orthopaedic surgeons frequently use opioids for peri-operative pain management and there is considerable variability in the amount prescribed between surgeons. As such, the appropriate number of opioids to prescribe for specific procedures is often unknown. Leftover prescription opioids are at risk for diversion to family and friends for nonmedical use. The aim of this study was to determine the optimal amount of narcotics to prescribe postoperatively for patients undergoing hip arthroscopy. 23 consecutive patients were enrolled. All patients were prescribed 60 tablets of hydrocodone/acetaminophen 10/325 postoperatively as part of a multimodal pain management strategy. Patients were called at 14 and 21 days post-operatively to tabulate the number of pills used and knowledge of how to properly dispose of pills. The median number of narcotic pain pills required was 6 (IQR: 3,15). Over half of patients (56.5%) required ≤10 narcotic pain pills postoperatively. A large number of narcotic tablets (1071/1380, 77.6%) were unused and a small percentage of patients (8/23, 34.8%) were aware of proper disposal techniques. Knowledge of how to properly dispose of unused narcotics was protective against a prolonged duration of narcotic use postoperatively (Parameter estimate −5.7, 95% CI: −11.3, −0.1, p = 0.045). Reducing the number of prescribed narcotic tablets to 25 would meet the post-operative pain demands of over 85% of hip arthroscopy patients. More judicious post-operative prescribing patterns and patient education regarding disposal may help minimize physician contribution to opioid misuse, overuse and diversion

Previous authors have suggested that the analgesic effects of intra-articular morphine may be beneficial. Clonidine has been found to potentiate the analgesic effect of morphine. Following knee arthroscopy, morphine has demonstrated equivocal effect in comparison to bupivicaine for analgesia while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine following hip arthroscopy. The purpose of this study was to evaluate the efficacy of intra-articular morphine in combination with clonidine on pain and narcotic consumption following hip arthroscopy surgery for femoroacetabular impingement. A retrospective review was performed on 43 patients that underwent hip arthroscopy between September 2014 and May 2015 at our institution for femoroacetabular impingement. All patients received preoperative Celebrex and Tylenol per our anesthesia protocol, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 mcg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the two groups. We found that patients who received intra-articular morphine and clonidine used significantly less opioid analgesic in the PACU, with 23 mEq of morphine equivalents required in the intra-articular morphine and clonidine group compared to 40 mEq of opiod equivalents in the non-injection group (p=0.0259). There were no statistically significant differences in time spent in recovery prior to discharge or in VAS pain scores recorded immediately post-operatively and at one hour following surgery. In conclusion, we found that an intraoperative intra-articular injection of morphine and clonidine significantly reduced the amount of narcotic requirement following hip arthroscopy. We do believe that there may be significant benefits to this, including less systemic effects from overall narcotic usage in the perioperative period. Our study demonstrated a beneficial effect of intra-articular morphine that may help with overall pain improvement, less narcotic consumption, and improved patient satisfaction following outpatient hip arthroscopy. This study provides the foundation for future research currently being conducted in a randomised-control setting

The use of spinal anesthesia with adjuvant intra-thecal opioids has been commonly used in total knee arthroplasty without documented clinical benefit. It has been associated with a potential increase in side effects, including nausea, vomiting, pruritus, urinary retention and oxygen usage. This double-blinded RCT investigated whether the addition of epimorph to spinal anesthesia in patients undergoing total knee arthroplasty resulted in superior pain control and decreased narcotic consumption without also causing an increase in postoperative complication rates. We performed a prospective double-blind trial in patients undergoing primary total knee arthroplasty (TKA). Patients were randomised to receive either spinal anesthesia alone or spinal anesthesia with epimorph (150 ug). All patients received infiltration of a local anesthetic cocktail intraoperatively. Both the study patients and staff measuring outcomes were blinded to the experimental treatment received during data collection. Postoperatively, visual analogue scale (VAS) for pain was recorded at 6, 12, 18, 24, 36 and 48hrs and a final value at 1 week. Narcotic use, Foley insertion, oxygen requirements, nausea, vomiting and pruritus were recorded during the course of hospitalisation. Forty-one patients were randomised into each of the spinal with epimorph and spinal alone treatment arms. The groups showed no significant differences in BMI, age, and gender distribution. In the first 12 hours postoperatively there was no difference in VAS for pain between the two groups, however there were significantly lower pain scores in the spinal alone patients at 18 hours (p=0.002), 24 hours (p=0.04) and 48 hours (p = 0.03) compared to the spinal with epimorph group. Narcotic usage was greater in the spinal group during the first 6 hours postoperatively, but beyond this time point narcotic usage was similar between the two groups. Additionally, there was a statistically significant increase in rate of complications with spinal epimorph including nausea (p=0.037) and pruritus (p=0.024). The incidence of urinary retention was greater in the spinal epimorph group, however this did not reach statistical significance. This study demonstrates no clinical benefit with the addition of intra-thecal opioids to spinal anesthetic in primary TKA. In addition to a failing to reduce VAS pain scores and overall narcotic consumption, increased complication rates were seen. For these reasons, this study does not support the use of epimorph in addition to spinal anesthesia for pain control in TKA

Symptomatic lumbar spinal stenosis is a common entity and increasing in prevalence. Limited evidence is available regarding patient reported outcomes comparing primary vs revision surgery for those undergoing lumbar decompression, with or without fusion. Evidence available suggest a lower rate of improvement in the revision group. The aim of this study was to assess patient reported outcomes in patients undergoing revision decompression, with or without fusion, when compared to primary surgery. Patient data was collected from the Canadian Spine Outcomes Research Network (CSORN) database. Patients undergoing lumbar decompression without or without fusion were included. Patients under 18, undergoing discectomy, greater than two level decompressions, concomitant cervical or thoracic spine surgery were excluded. Demographic data, smoking status, narcotic use, number of comorbidities as well as individual comorbidities were included in our propensity scores. Patients undergoing primary vs revision decompression were matched in a four:one ratio according to their scores, whilst a separate matched cohort was created for those undergoing primary vs revision decompression and fusion. Continuous data was compared using a two-tailed t-test, whilst categorical variables were assessed using chi-square test. A total of 555 patients were included, with 444 primary patients matched to 111 revision surgery patients, of which 373 (67%) did not have fusion. Patients undergoing primary decompression with fusion compared to revision patients were more likely to answer yes to “feel better after surgery” (87.8% vs 73.8%, p=0.023), “undergo surgery again” (90.1% vs 76.2%, P=0.021) and “improvement in mental health” (47.7% vs 28.6%, p=0.03) at six months. There was no difference in either of these outcomes at 12 or 24 months. There was no difference between the groups ODI, EQ-5D, SF 12 scores at any time point. Patients undergoing primary vs revision decompression alone showed no difference in PROMs at any time point. In a matched cohort, there appears to be no difference in improvement in PROMS between patients undergoing primary vs revision decompression, with or without fusion, at two year follow-up. This would suggest similar outcomes can be obtained in revision cases

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

This study aims to 1) determine reported cannabis use among patients waiting for thoracolumbar surgery and to 2) identify demographics and health differences between cannabis-users and non-cannabis users. This observational cohort study is a retrospective national multicenter review data from the Canadian Spine Outcomes and Research Network registry. Patients were dichotomized as cannabis users and non-cannabis users. Variables of interest: age, sex, BMI, smoking status, education, work status, exercise, modified Oswestry Disability Index (mODI), the Numerical Rating Scales (NRS) for leg and back pain, tingling/numbness scale, SF-12 Quality of Life Questionnaire - Mental Health Component (MCS), use of prescription cannabis, recreational cannabis, and narcotic pain medication. Continuous variables were compared using an independent t-test and categorical variables were compared using chi-square analyses. Cannabis-use was reported by 28.4% of pre-operative patients (N=704), 47% of whom used prescription cannabis. Cannabis-use was reported most often by patients in Alberta (43.55%), British Colombia (38.09%) and New Brunswick (33.73%). Patients who reported using cannabis were significantly younger (mean=52.9 versus mean=61.21,). There was a higher percentage of concurrent narcotic-use (51.54 %) and smoking (21.5%) reported in cannabis-users in comparison to non-cannabis users (41.09%,p=0.001; 9.51%, p=0.001, respectively). There were significant differences in cannabis-use based on pathology (p=0.01). Patients who report using cannabis had significantly worse MCS scores (difference=3.93, p=0.001), and PHQ-8 scores (difference=2.51, p=0.001). There was a significant difference in work status (p=0.002) with cannabis-users reporting higher rates (20%) of being employed, but not working compared to non-cannabis users (11.13%). Non-cannabis users were more likely to be retired (45.92%) compared to cannabis-users (31.31%). There were no significant differences based on cannabis use for sex, education, exercise, NRS-back, NRS-Leg, tingling-leg, mODI, or health state. Thoracolumbar spine surgery patients are utilizing cannabis prior to surgery both through recreational use and prescription. Patients who are using cannabis pre-operatively did not differ in regards to reported pain or disability from non-users, though they did in demographic and mental health variables

Prolonged length of stay (LOS) is a significant contributor to the variation in surgical health care costs and resource utilization after elective spine surgery. The primary goal of this study was to identify patient, surgical and institutional variables that influence LOS. The secondary objective is to examine variability in institutional practices among participating centers. This is a retrospective study of a prospectively multicentric followed cohort of patients enrolled in the CSORN between January 2015 and October 2020. A logistic regression model and bootstrapping method was used. A survey was sent to participating centers to assessed institutional level interventions in place to decrease LOS. Centers with LOS shorter than the median were compared to centers with LOS longer than the median. A total of 3734 patients were included (979 discectomies, 1102 laminectomies, 1653 fusions). The median LOS for discectomy, laminectomy and fusion were respectively 0.0 day (IQR 1.0), 1.0 day (IQR 2.0) and 4.0 days (IQR 2.0). Laminectomy group had the largest variability (SD=4.4, Range 0-133 days). For discectomy, predictors of LOS longer than 0 days were having less leg pain, higher ODI, symptoms duration over 2 years, open procedure, and AE (p< 0.05). Predictors of longer LOS than median of 1 day for laminectomy were increasing age, living alone, higher ODI, open procedures, longer operative time, and AEs (p< 0.05). For posterior instrumented fusion, predictors of longer LOS than median of 4 days were older age, living alone, more comorbidities, less back pain, higher ODI, using narcotics, longer operative time, open procedures, and AEs (p< 0.05). Ten centers (53%) had either ERAS or a standardized protocol aimed at reducing LOS. In this study stratifying individual patient and institutional level factors across Canada, several independent predictors were identified to enhance the understanding of LOS variability in common elective lumbar spine surgery. The current study provides an updated detailed analysis of the ongoing Canadian efforts in the implementation of multimodal ERAS care pathways. Future studies should explore multivariate analysis in institutional factors and the influence of preoperative patient education on LOS

Introduction. There is no consensus on the ideal pain management strategy following total hip arthroplasty (THA). This study sought to identify immediate changes in the hospital course of patients undergoing primary THA following implementation of a rapid recovery anesthesia and multimodal management of pain (RAMP) protocol. For this study, rapid recovery anesthesia describes the use of preoperative non-narcotic medication in conjunction with neuraxial anesthesia techniques confined to the operating room only. The multimodal pain regimen consists of pre- and post-operative high dose nonsteroidal anti-inflammatories (NSAIDs), gabapentin, and antiemetics with or without intraoperative periarticular anesthetic injection. We hypothesized that the implementation of a RAMP protocol would lead to decreased reported pain scores, decreased narcotic use, and a shorter hospital stay in patients undergoing primary THA. Methods. This retrospective cohort study performed at a multi-surgeon high-volume institution reviewed the records of 81 consecutive patients who underwent primary THA utilizing traditional anesthesia and an opioid-dependentpain management techniques between June to September 2014 compared to 78 patients who underwent primary THA after implementation of the RAMP protocol between November 2014 to February 2015. The length of stay (LOS), pain scores, narcotic use, and other clinical data were recorded for each study group. Equality of variance was confirmed prior to statistical analysis using t-test for equality of means. Results. There was no significant difference in the demographics, body mass index, ASA classification, or Charleson Comorbidity Index between the two cohorts. The average LOS was significantly shorter after implementation of the RAMP protocol with a mean of 2.10 ± 1.1 days versus 2.89 ± 1.0 days. Total amount of narcotics used was significantly less with the RAMP protocol (Fig 1). Patient reported pain scores were improved throughout the hospital stay with patients receiving the RAMP protocol reporting significantly less pain beginning the morning of POD 1 (Fig 2). No significant decrease in kidney function was seen following the use of high dose NSAIDs (p=0.18). Conclusions. The implementation of a RAMP protocol in patients undergoing primary total hip arthroplasty has resulted in an immediate shorter length of stay with less narcotics use and improved reported pain scores. To our knowledge, this is the first study demonstrating a statistically significantly shorter length of stay associated with a multimodal pain protocol. This study supports the benefits of broad implementation a RAMP protocol for total hip arthroplasty

Despite total knee arthroplasty demonstrating high levels of success, 20% of patients report dissatisfaction with their result. Wellness Stasis Socks are embedded with a proprietary pattern of neuro-receptor activation points that have been proven to activate a precise neuro-response, as according to the pattern theory of haptic perception, which stimulates improvements in pain and function. Technologies that manipulate this sensory environment, such as textured insoles, have proven to be effective in improving gait patterns in patients with knee osteoarthritis. In regard to patients undergoing TKA using this new technology may prove beneficial as an adjunct to recovery as many patients suffer from further deficits to their proprioceptive system caused by ligamentous damage and alterations to mechanoreceptors during procedure. We hypothesized that the Wellness Stasis Socks are a safe, cost-effective and easily scalable strategy to support TKA patients through their recovery. Double-blinded, placebo-controlled randomized trial. Randomization using a computer-generated program . All study coordinators, healthcare personel and patients were blinded to patient groups. All surgical procedures were conducted by the same technique and orthopaedic surgeon. Intervention group: Wellness Stasis socks containing receptor point-activation technology. Control group: indentical appearing Wellness Stasis socks without receptor point-activation technology. Sock use during the waking hours . All additional post-operative protocols remained consistent between groups including same facility physiotherapy . Additional modalities (ice machines, soft-tissue massages, acupuncture) were prohibited. WOMAC questionnaire completed at baseline, 2 weeks, and 6 weeks to assess pain, stiffness and physical function. G. *. Power software to determine minimum sample of 50 in each group. No patients were lost to follow up and all followed study protocol. Data analysis using SPSS software. P-values, effect sizes, and confidence intervals are reported to assess clinical relevance of the finding. Physical status classifications were compared using t-test. Within-subject and between-subject differences in the mean WOMAC were analyzed by ANOVA. Cramer's V statistical analysis noted that other variables of Sex, BMI, ASA classification and Age were not statistically different between the control and intervention groups. No statistical difference between groups in Preop Womac scores. The data showed a consistent improvement in Womac scores for pain and stiffness at 2 weeks post op in the interventional group over the control group. The womac scores assessing physical function showed a consistent improvement at both 2 and 6 weeks post op in the intervention group compared to the control group. There were no complications in either group associated the sock use. The intervention proved to be a low cost and safe additional intervention post operatively from TKA to help patients improve with regard to pain, stiffness and physical function. This study suggests this modality can be added to the list of other commonly used post op interventions such as cryocuffs, physiotherapy, and relaxation techniques as safe post op interventions to help patients improve post op TKA and can act as an adjunct in providing non narcotic pain control

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

Over the past fifteen years, the average length of stay for total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and perioperative protocols. Rapid recovery techniques and perioperative protocols have been refined to allow for same-day discharge with improved outcomes. As mentioned, the single most important outcome from the minimally invasive movement has been the multi-modal approach to pain management of patients undergoing arthroplasty. Along with blood loss management, using tranexamic acid and hypotensive anesthetic techniques, this multi-modal program is the most important variable in reducing or avoiding side-effects. In any arthroplasty procedure, side-effects that need to be addressed include the negative effects of narcotics and blood loss. Anesthetic techniques, utilizing local nerve blocks, such as the adductor canal block and sciatic blocks for knee arthroplasty augment intraoperative anesthesia and provide postoperative pain relief and quicker mobilization. Additionally, pericapsular injection with a cocktail of local anesthetic helps significantly with pain relief and recovery reducing the amount of oral narcotic utilised in the early postoperative period. Many have utilised liposomal bupivacaine in these cocktails to successfully increase the period of pain relief. The use of multi-modal perioperative protocols can help avoid narcotics and helps avoid the side-effects of nausea. We also utilise an aggressive prophylactic antiemetic program with dexamethasone, ondansetron and a scopolamine patch. Patients without any significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately two weeks postoperatively. Immediately postoperative, acetaminophen and additional dexamethasone are administered intravenously. The multi-modal protocols to address fear, risk, and side-effects will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. By focusing on the patient and avoiding over-treatment, outpatient arthroplasty is quickly becoming the standard of care for total hip replacement in the same way other procedures transitioned from hospital in-patient surgeries to ambulatory procedures

Introduction. Direct anterior approach (DAA) total hip arthroplasty (THA) has been reported to improve early outcomes as compared to posterior approach THA up to 6 weeks post-operatively. However, very few detailed results have been reported within the first 6 weeks. In this study we investigate the effect of surgical approach on THA outcome via weekly assessment. Methods. Patients undergoing THA for primary osteoarthritis were prospectively enrolled. Data was collected pre-operatively and post-operatively at weekly intervals for 6 weeks. Outcome scores and additional functional measures were compared using unpaired t-test, effect size, and Pearson correlation coefficients. Results. 111 patients (55 DAA and 56 posterior approach) were enrolled. There was no significant difference (p>0.05) in pre-surgical Patient Reported Outcome Measurement Information System (PROMIS) Pain interference and Physical Function scores, VAS Pain, and Modified Harris Hip Scores (mHHS). Post-operatively, the DAA group had decreased length of stay [1.4 vs 2.2 days, p=0.0002] and increased distance walked on postoperative day 1 and 2 [95 vs 52 ft, p=0.011 and 251 vs. 163 ft, p=0.0004, respectively]. The DAA group had lower VAS pain scores [p<0.05] and required less day 1 and total narcotics [59 vs 80 morphine equivalents, p=0.029 and 138 vs 190, p=0.01, respectively]. The DAA cohort had improved PROMIS Physical Function scores and mHHS up to 5 weeks post- operatively. Anterior approach patients discontinued their assistive device 8 days earlier [p=0.01], left home 3 days earlier [p=0.001], and drove a car 5 days earlier [p=0.016] compared to posterior patients. Conclusion. Patients undergoing DAA THA had significantly shorter length of stay, improved mobilization, decreased narcotic requirements and improved inpatient VAS pain scores compared to mini-posterior THA. Furthermore, DAA patients discontinued their assistive device, left their home, and drove a car sooner than posterior approach patients. The significant improvement in physical function seen with DAA THA persisted up to 5 weeks post-operatively

Introduction. Pain control following total knee arthroplasty (TKA) heavily influences timing of mobilization and rehabilitation postoperatively as well as length of hospital stay. Recently, periarticular injection of liposomal bupivacaine (EXPAREL®; Pacira Pharmaceuticals, Inc., San Diego, California) has demonstrated pain relief comparable to femoral nerve block for postoperative analgesia in TKA with earlier mobilization and shortened hospital stay. In order to better explore the use of EXPAREL® in TKA, we standardized the postoperative analgesia to intraoperative periarticular injection of multimodal pain management, which is a recommended postoperative method of pain control in TKA. We studied the effectiveness of periarticular EXPAREL® in TKA postoperative pain control, including impact on early mobilization and length of hospital stay, compared to another local analgesic (Ropivacaine) when both are used as part of a multimodal pain management approach. Methods. We performed a double blind, randomized, controlled, prospective, IRB-approved study that enrolled 96 participants who underwent a unilateral TKA by one surgeon between May 2014 and March 2015. The two randomized groups were as follows: group 1 (control group) was given the standard intra-articular “pain cocktail” injection, consisting of ropivacaine, ketorolac, morphine, and epinephrine mixed with saline into a 100cc preparation and group 2 (study group) was given a similar intra-articular injection consisting of bupivacaine, ketorolac, morphine, and epinephrine mixed with saline into an 80cc preparation as well as an injection of EXPAREL®, 20cc of 1.3% EXPAREL®, to total 100cc. All patients included in the study were determined to be opioid naïve as described by the Food and Drug Administration criteria. Patients were treated with the same postoperative pain management protocol as well as the same post-operative physical therapy program. The consumption of oral and intravenous narcotics at specific time points as well as total use was recorded during hospital stay. We recorded Visual Analog Pain scores, hours to ambulate 100 feet and length of hospital stay (hours). Both the investigator and the patient were blinded as to which group the patient was randomized, making this a double blind study. Results. On a per hour basis, the mean use of narcotics of the two groups differed by only 0.1mg. For total narcotic use during hospital stay, the weighted sum used by patients in the EXPAREL® group, 97.7mg of hydrocodone ±42.84 mg, exceeded the weighted sum, 89.6 mg of hydrocodone ± 58.57 mg, used by patients in the control group. The difference between the two groups was not significant. The means for length of stay differed by only 26 minutes and the difference was not significant. Similarly insignificant, the means for the time to ambulate 100 feet differed by 53 minutes, with the EXPAREL® group actually taking the longer time. The two groups did not differ for Visual Analog Score for pain on day 1 or day 2 post-operatively. Conclusion. When comparing the use of EXPAREL® to another multimodal pain management approach using ropivacaine, there is no difference in post-operative opioid consumption, Visual Analong Scores for pain, amount of time to ambulate or length of hospital stay

The importance of mitigating pain for patients undergoing total shoulder arthroplasty is extremely relevant for purposes of being able to initiate early functional rehabilitation and activities of daily living. The process, however, does not commence after surgery but rather before surgery. Careful patient education and instruction, including pre-operative exercises to maximise mobility, strength and endurance within the limited range of motion is quite helpful. Adjunctive therapy includes preemptive ultrasound-guided intrascalene regional anesthesia, immediate post-operative peri-incisional injection of liposomal bupivacaine, post-operative use of waterproof Tegaderm. TM. dressing to allow warm showers early on in the rehabilitation period, peri-operative use of Cox 2 inhibitors and a gentle, therapist-guided passive exercise program focusing on relaxation techniques. This in combination with patient-controlled analgesic pumps, careful surgical technique providing adequate soft tissue releases and removal of potential pain generators such as the long tendon of the biceps and an arthritic AC joint all contribute to the minimization of the patient's pain experience, and offers relatively early weaning from parenteral narcotics in the first 24 hours, and oral narcotics within the first 7–10 days post-operatively

Introduction. Liposomal bupivacaine has been shown to be effective in managing post-operative pain in hallux valgus and hemorrhoid surgery. However, non-industry-supported and well-powered randomized studies evaluating its efficacy in Total Knee Arthroplasty (TKA) are lacking. Our hypothesis was that liposomal bupivacaine would not decrease post-operative visual analog pain scores (VAS) or narcotic consumption in the acute post-operative period. Methodology. Two hundred seven consecutive patients were enrolled into a single-blinded prospective randomized study. We included patients undergoing unilateral TKA by five fellowship-trained surgeons with a diagnosis of osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis. Patients were excluded for any other diagnosis necessitating TKA, allergy to the medications, or pre-operative opiate use. Participants received standardized pain management, anesthesia, and physical therapy. Patients were randomized intra-operatively to one of three groups: an intra-articular (IA) injection of bupivacaine and morphine at the conclusion of the procedure, a peri-articular (PA) injection of a bupivacaine and morphine, or a PA injection of liposomal bupivacaine. Post-operative pain VAS and mean morphine equivalents (MME) consumed were recorded and compared utilizing analysis of variance (ANOVA). A power analysis demonstrated that 159 patients were needed for 80% power to detect a 25% difference in VAS or MME. Results. Patients in each study group had a mean VAS score of 3.95 (SD 2.1), 3.97 (SD 1.9). and 3.86 (SD 1.8) (p=0.94), respectively. MME consumed per day in each group was 100.7 (SD 48.4), 100.1 (SD 42.2), and 98.9 (SD 41.6) (p=0.97). Conclusion. Liposomal bupivacaine does not alter mean pain scores or post-operative narcotic consumption in patients undergoing unilateral TKA. Further, no difference was noted in comparing patients who received a single IA injection versus a PA injection. To our knowledge, this is the first reported study to evaluate post-operative pain control between identical IA and PA injections in patients undergoing unilateral TKA

TKR is a standard procedure for knee joint falure. Besides surgical technique, the main concerns at the perioperative care are: infection prophylaxis, blood loss management, & pain control. Pain is a normal part during the post-operative recovery stage. Currently, I apply multimodal pain control cocktails: Parenteral narcotics (as pethidine, tramadol, morphine), oral analgesics (as NSAIDs, Acetaminophen, opioids), PCA (Patient controlled analgesia), LIA (local IA injection anesthetics, Marcaine), and immediate Ice Packing. How about the usage of transdermal, non-opioid devices as Lidocaine patch. It shows the advantages of: less invasiveness, less ambulation-impeding, easy monitor & control, patient-activated, and absence of opioid-induced complications. Also it can be an adjuvant in the multi-modal anesthesia. In this Randomized prospective study, we investigate the analgesic effects of various transdermal non-opioid patches in patients after elective TKR. Conclusion. The use of non-opioid transdermal patches is a safe and patient-activated method. Non-opioid transdermal patches show NSD improvement in the postoperative pain control for patients underwent TKA, facilitating fewer narcotics consumption, fewer breakthrough pain, faster recovery in movements and even shorter stay. However, without obvious differences, the routine use of transdermal patches in current pain control protocol should be trade-off

Anesthetic peripheral nerve blocks (PNB) have been shown to be more advantageous than general anesthesia in a variety of surgical operations. In comparison to conventional methods of general anesthesia, the choice of regional localized infiltration has been shown to shorten hospital stays, decrease hospital readmissions, allow early mobilization, and reduce narcotic use. Perioperative complications of PNBs have been reported at varying rates in literature. Thus, the purpose of this study was to provide a review on the clinical evidence of PNB complications associated with foot and ankle surgeries. A systematic review of the literature was completed using PubMed search terms: “lower extremity”, “foot and ankle”, “nerve block”, and “complications”. All studies reporting minor and major complications were considered along with their acute management, treatments, and postoperative follow up timelines. The range of complications was reported for Sensory Abnormalities, Motor Deficits, Skin and systemic complications (local anesthetic systemic toxicity & intravascular injections). A designation of the scientific quality (Level I-IV) of all papers was assigned then a summary evidence grade was determined. The search strategy extracted 378 studies of which 38 studies were included after criteria review. Block complications were reported in 20 studies while 18 studies had no complications to report. The quality of evidence reviewed ranged from Level I to Level IV studies with follow up ranging from twenty four hours to one-three year timelines. The range of complications for all studies reporting sensory abnormalities was 0.53 to 45.00%, motor deficits 0.05 to 16.22% and skin and systemic complications 0.05 to 6.67%. Sensory abnormalities that persisted at last follow up occurred in six studies with incidence ranging from 0.23 to 1.57%. Two studies reported motor complications of a foot drop with an incidence of 0.05% and 0.12%. When considering only the highest quality studies (Level 1) that had complications to report, the complications rate was 10.00% to 45.00% for sensory abnormalities, 7.81 to 16.22% for motor deficits, 6.67% for skin complications and 2.50% for systemic complications. High quality studies (Level I providing Summary Grade A Evidence) reporting all complications with a range of incidence from 0 to 45%. While most of these complications were not serious and permanent, some were significant including sensory abnormalities, foot drop and CRPS. Based on this systematic review of the current literature, the authors emphasize a significant rate of complications with PNB and recommend that patients are appropriately informed prior to consenting to these procedures

Perioperative glucocorticoids have been used as a successful non-opioid analgesic adjunct for various orthopaedic procedures. Here we describe an ongoing randomized control trial assessing the efficacy of a post-operative methylprednisolone taper course on immediate post-operative pain and function following surgical distal radius fixation. We hypothesize that a post-operative methylprednisolone taper course following distal radius fracture fixation will lead to improved patient pain and function. This study is a randomized control trial (NCT03661645) of a group of patients treated surgically for distal radius fractures. Patients were randomly assigned at the time of surgery to receive intraoperative dexamethasone only or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course. All patients received the same standardized perioperative pain management protocol. A pain journal was used to record visual analog pain scores (VAS-pain), VAS-nausea, and number of opioid tablets consumed during the first 7 post-operative days (POD). Patients were seen at 2-weeks, 6-weeks, and 12-weeks post-operatively for clinical evaluation and collection of patient reported outcomes (Disabilities of the Arm, Shoulder and Hand Score [qDASH]). Differences in categorical variables were assessed with χ2 or Fischer's exact tests. T-tests or Mann-Whitney-U tests were used to compare continuous data. Forty-three patients were enrolled from October 2018 to October 2019. 20 patients have been assigned to the control group and 23 patients have been assigned to the treatment group. There were no differences in age (p=0.7259), Body Mass Index (p=0.361), race (p=0.5605), smoking status (p=0.0844), or pre-operative narcotic use (p=0.2276) between cohorts. 83.7% (n=36) of patients were female and the median age was 56.9 years. No differences were seen in pre-operative qDASH (p=0.2359) or pre-operative PRWE (p=0.2329) between groups. In the 7 days following surgery, patients in the control group took an average of 16.3 (±12.02) opioid tablets, while those in the treatment group took an average of 8.71 (±7.61) tablets (p=0.0270). We see that significant difference in Opioid consumption is formed at postoperative day two between the two groups with patients in the control group taking. Patient pain scores decreased uniformly in both groups to post-operative day 7. Patient pain was not statistically from POD0 to POD2 (p=0.0662 to 0.2923). However, from POD4 to POD7 patients receiving the methylprednisolone taper course reported decreased pain (p=0.0021 to 0.0497). There was no difference in qDASH score improvement at 6 or 12 weeks. Additionally, no differences were seen for wrist motion improvement at 6 or 12 weeks. A methylprednisolone taper course shows promise in reducing acute pain in the immediate post-operative period following distal radius fixation. Furthermore, although no statistically significant reductions in post-operative opioid utilization were noted, current trends may become statistically significant as the study continues. No improvements were seen in wrist motion or qDASH and continued enrollment of patients in this clinical trial will further elucidate the role of methylprednisolone for these outcomes