Volume 23-1, Spring 2014

The purpose of the current study is to identify patients who are at high risk for rehospitalization, revision, complications, and mortality after outpatient and short-stay total knee arthroplasty (TKA). The medicare 5% limited data set sample was used to identify patients with a TKA procedure who were treated in an outpatient setting or who were discharged within 1 or 2 days in the hospital setting. Rehospitalization risk increased with higher Charlson score (i.e., poorer health status), older patients, inpatients (vs. outpatients), patients not receiving a femoral nerve block, earlier (vs. recent) year of surgery, and those with a recent history of heart failure. The findings of this study suggest that existing comorbidities, particularly heart failure, have the greatest effect on event risk after outpatient and short-stay TKA. The information obtained from this study should assist with patient selection for TKA performed on an outpatient basis. Key words: comorbidities, outpatient, patient selection, revision, short stay, total knee arthroplasty

DepoDur, an extended-release epidural morphine, has been used effectively for postoperative pain control following many orthopaedic and general surgery procedures and has provided prolonged analgesia when compared with Duramorph. The goal of this article was to compare the safety and analgesic efficacy of DepoDur versus Duramorph after lumbar spine surgery. A prospective, randomized, double-blind clinical study was completed at a single extended-stay ambulatory surgery center. All patients over 18 undergoing posterior lumbar spine fusions were considered for the study. Sixty patients were randomly assigned to a control or treatment group. The control group received DepoDur before surgery, while the treatment group received Duramorph. Although results show no significant differences between the two groups in postoperative visual analog pain scale scores, use of pain medication, and adverse events, subjects receiving DepoDur were less likely to receive Naloxone and oxygen supplementation, experience nausea or fever, and were more likely to experience hypotension. DepoDur proved to be safe and effective, offering similar prolonged analgesic activity when compared with Duramorph. Key words: analgesic, DepoDur, Duramorph, epidural morphine

Total hip arthroplasty (THA) has been shown to improve long-term quality of life, although the immediate postoperative period can be associated with intense postoperative pain that hampers rehabilitation. Effective postoperative analgesia is paramount in the recovery period. The understanding and collaboration of the orthopaedic surgeon and the pain-management physicians will improve the perioperative outcome of THA. Appropriate pain management can reduce the associated total direct medical costs for lower extremity joint replacement surgeries by reducing hospital stays and the services needed during hospitalization. Factors contributing to the shorter lengths of stay include homogenous entities such as regular staff and continuity of nursing care, the use of timely and up-to-date information including expectations on a short stay, functional discharge criteria, early mobilization, and the use of a multimodal analgesia approach centered on opioid sparing. Key words: pain, total knee arthroplasty

Pain management following total knee arthroplasty (TKA) can be challenging. Inadequate pain management following TKA may inhibit rehabilitation, increase morbidity and mortality, decrease patient satisfaction, and lead to chronic persistent postsurgical pain. Traditionally the mainstay of postoperative pain management was opioids; however, the current recommendations to pain management emphasize a multimodal approach and minimizing opioids whenever possible. With careful planning and a multimodal analgesic approach instituted perioperatively, appropriate pain management following TKA can be achieved. Utilizing an extensive review of the literature, this article discusses the analgesic techniques available for the perioperative management of TKA. Key words: perioperative pain management, TKA

The utilization of multimodal pain management following total joint arthroplasty (TJA) has positively affected the quality of postoperative care, reduced surgical pain, and decreased the magnitude of opioid consumption and subsequent dose-related complications. The advent of liposomal bupivacaine is proving to be a highly efficacious and safe method of postoperative pain management with favorable pharmacokinetics that reduces the risk of amide-related toxicity. Additionally, the therapeutic levels of bupivacaine, which are below the toxic range and sustained for 72 hours after injection, are providing an effective mechanism for early hospital discharge and rapid recovery after TJA. This article reviews the rationale behind liposomal bupivacaine, its mechanism of action, pharmacokinetics, indications, and contraindications for use. Key words: bupivacaine, DepoFoam, liposomal, pain, total joint

This case report describes the course of a 26-year-old male who developed a dense motor palsy of the radial nerve after receiving a seasonal influenza vaccination. The palsy developed within 12 to 16 hours of inoculation and demonstrated no clinical recovery until 5 months postinjury. Electromyographic and nerve conduction studies obtained at six weeks postinjury were consistent with complete motor denervation. Sensory function was preserved. The injury was successfully treated nonoperatively with physical therapy and wrist splinting, and the palsy gradually resolved over the next several months. Key words: influenza vaccination, Parsonage–Turner radial nerve palsy, postvaccination neuropathy

Intraneural bone was identified on pathologic examination of a neuroma-in-continuity resected for repair of the suprascapular nerve 4 months after a brachial plexus injury. The acute onset of the neurologic deficit, the location of the neuroma within the scapular notch, and the proximity of the neural pathology to a comminuted scapula fracture suggest traumatic penetration of the nerve by a bone fragment. To the authors’ knowledge, the observation of bone within a neuroma has not been previously reported. Key words: brachial plexus injury, nerve graft, neurorrhaphy, suprascapular nerve, trauma

Visualization of the three-dimensional nature of a Hill–Sachs lesion during osteoarticular allografting via an anterior approach is challenging and makes fashioning of an appropriately sized shape-matched graft difficult. A technique using bone wax to aid in templating the size and shape of the Hill–Sachs lesion for grafting is described. Key words: bone wax, Hill–Sachs, osteoarticular allograft, osteochondral allograft