Volume 24-4, Winter 2015

Our careers as medical professionals are unquestionably a big part of our lives. But another and perhaps even larger part of who we are appears after we take off the white coat. Each of us has a story to share about who we are beyond the white coat. This editorial is the story of a friendship. Bill Capello and Jim D’Antonio are two orthopaedic surgeons whose friendship has spanned more than five decades. That friendship shaped, and continues to shape, both of their lives.

The hypothesis was that agents delivered intra-articularly after knee arthroscopy will be diluted by residual arthroscopic fluid. Diagnostic arthroscopy was performed on six cadaver knees. Each procedure was followed by an intra-articular injection of a dye solution. Intra-articular aspirates were gathered from three locations.With significance set at p < .05, the aspirates were compared with the initial dye concentration and with each other. No significant difference was noted among the sites, indicating that no specific knee area was exposed to a higher dye concentration. There was a significant difference in dye concentration of the aspirates when compared with the dye’s initial concentration. The concentration of fluid injected intra-articularly after arthroscopy was diluted by 27%. These data indicate that agents injected into the knee postarthroscopy are significantly diluted. In vitro and in vivo experiments evaluating chondrotoxicity of various anesthetic agents may not accurately reflect the actual concentration of the drug within the knee joint unless dilution effects are taken into account. (Journal of Surgical Orthopaedic Advances 24(4):209–212, 2015) Key words: arthroscopic surgery, injection location, intra-articular gradient, intra-articular injections

Evidence-based guidelines have recently been published for the nonarthroplasty treatment of osteoarthritis of the hip and knee and are becoming an expected part of comprehensive patient care. To understand how current treatment practices correlate with these guidelines, a survey was administered to 50 consecutive hip replacement and 50 consecutive knee replacement patients immediately before arthroplasty for osteoarthritis in one group practice. This article is a compilation of patients’ usage of the modalities suggested in two such exemplary guidelines and demonstrates that patient and surgeon preferences, as well as factors such as preoperative Oxford score, body mass index, age, and joint involved, affect usage of one or more of the commonly employed preoperative modalities. This information provides orthopaedic surgeons and administrators with a compilation of responses that reflects surgeon and patient preferences for treatment before surgery. (Journal of Surgical Orthopaedic Advances 24(4):213–220, 2015) Key words: clinical practice guideline, nonsurgical treatment, osteoarthritis, total hip replacement, total knee replacement

The purpose of the current study was to identify and map the periarticular neural anatomy of the hip to optimize periarticular injection techniques in total hip arthroplasty. A literature review of common search engines was performed using terms associated with hip innervation and 17 met the inclusion criteria. The studies addressed both gross and microscopic neural anatomy of the human hip joint, and the findings summarize key areas of hip mechanoreceptors and free nerve endings to provide a framework for targeted periarticular hip infiltration. Grossly, the hip joint is supplied by the femoral, obturator, sciatic, and superior gluteal nerves, as well as the nerve to the quadratus femoris. The greatest concentration of sensory nerve endings and mechanoreceptors is found at the anterior hip capsule, especially superiorly. The labrum is most highly innervated from the 10 to 2 o’clock position. After the cup and liner are placed, periarticular injections should be infiltrated toward the remnant labrum from 10 to 2 o’clock. Before stem insertion, the visible periosteum may then be injected circumferentially about the femur. The anterior and superior capsular tissue, if retained, is routinely infiltrated at the time of capsular repair. Depending on surgical approach, the fascia and incised soft tissue are infiltrated before final closure. (Journal of Surgical Orthopaedic Advances 24(4):221–224, 2015) Key words: anesthesia, injection, innervation, nerve anatomy, periarticular, total hip arthroplasty

This study sought to evaluate opioid consumption, hospitalization costs, and length of stay when surgical site periarticular infiltration of liposomal bupivacaine is used after total knee arthroplasty (TKA). Sixty-six consecutive primary TKA cases performed with a single-injection femoral nerve block before this date were compared with 59 consecutive TKA cases performed with the liposomal bupivacaine cocktail after this date. The mean amount of postsurgical opioids consumed was 199 mg versus 121 mg (pD.075), the average hospitalization cost was $28,546 versus $26,472 (p<.001), and the average length of stay was 2.05 days versus 1.58 days (p<.001) in the femoral nerve block versus liposomal bupivacaine group, respectively. There were no significant demographic differences between the two groups. Liposomal bupivacaine infiltration before primary wound closure may be an effective means in lowering hospitalization costs, decreasing length of stay, and decreasing postsurgical opioid consumption after TKA. (Journal of Surgical Orthopaedic Advances 24(4):225–229, 2015) Key words: femoral nerve block, hospitalization costs, length of stay, liposomal bupivacaine (Exparel), patient-controlled analgesia, TKA

The purpose of this study was to compare periarticular injection of liposomal bupivacaine (LB) to epidural analgesia as part of multimodal pain management strategy for total knee arthroplasty (TKA). A retrospective review of 50 patients undergoing TKA compared 25 patients who received LB to 25 patients who received an epidural. After postoperative day 1, patients who received LB exhibited significantly lower (p<.001) pain scores than those who received an epidural. Patients who received LB also had a significantly shorter length of hospital stay (p<.0001), greater range of motion on postoperative day 1, and walked significantly farther (p<.001) on postoperative day 1. LB appears to provide effective pain control leading to shorter hospital stays and improved early physical function compared with standard pain management with an epidural. (Journal of Surgical Orthopaedic Advances 24(4):230–234, 2015) Key words: liposomal bupivacaine, pain management, periarticular injection, total knee arthroplasty

Insufficient control of pain after total hip arthroplasty (THA) can delay rehabilitation and adversely affect long-term surgical outcomes. The current study directly compares 36 THA patients who were given a routine wound infiltration (RWI group) with 36 patients who were administered an injection of liposomal bupivacaine infiltration (LBUP group). Average visual analog scale pain scores were significantly higher for RWI patients (2.20 vs. 1.34, p = .0013) overall and trended higher for each day after surgery up to day 5. The average number of opioid doses was 13.14 for the RWI group compared with 4.97 for the LBUP group (p < .0001), and the total opioid dosage consumed was greater in the RWI group (105.4 vs. 72.3, p = .0075; significant only in regression model). The results of this study support the conclusion that liposomal bupivacaine infiltration, as part of a multimodal program after THA, can improve postoperative analgesia and reduce opioid consumption when compared with routine wound infiltration. (Journal of Surgical Orthopaedic Advances 24(4):235–241, 2015) Key words: analgesia, liposomal bupivacaine, total hip arthroplasty, wound infiltration

Low health literacy is associated with a poorer ability to understand and follow health instructions and advice, poorer health outcomes, and poorer use of health care services. Patients with low health literacy have difficulty accessing and understanding online health materials that are not written in plain language. This study assessed the readability of patient education materials that are focused on pain, a significant contributor to clinical outcomes after orthopaedic surgery. Results revealed that the overall mean readability level of the documents that were accessed online was higher than the 10th grade. Efforts should focus on making patient education easier to understand for the nearly 80 million Americans who struggle with health literacy. (Journal of Surgical Orthopaedic Advances 24(4):242–245, 2015) Key words: health literacy, pain, patient education, readability

Of 904 patients who underwent primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) at the same hospital, 802 participated in a preoperative education day called ‘‘Joint Academy’’ (JA). The length of stay of JA participants was 2.12 days (49.5%) less than patients who did not attend a JA (p < .01). JA attendees were 62% more likely to be discharged to home (p < .01) and had an average internal hospital cost $1,493 (18.9%) lower than the non-JA group (p < .01). Total costs incurred by JA attendees averaged $4,016 (27.2%) less than total costs for those patients who did not participate in a JA (p < .01). Patient participation in a preoperative education program may significantly reduce overall costs for primary TKA and THA procedures. (Journal of Surgical Orthopaedic Advances 24(4):246–251, 2015) Key words: cost reduction, patient education, total hip arthroplasty, total knee arthroplasty

Previous work, now nearly 30 years dated, is frequently cited as the ‘‘gold standard’’ for the indications and contraindications for medial unicompartmental knee arthroplasty (UKA). The purpose of this article is to review current literature on the indications and contraindications to UKA and develop a consensus statement based on those data. Six surgeons with a combined experience of performing more than 8,000 partial knee arthroplasties were surveyed. Surgeons then participated in a discussion, emerging proposal, collaborative modification, and final consensus phase. The final consensus on primary indications and contraindications is presented. Notably, the authors provide consensus on previous contraindications, which are no longer considered to be contraindications. The authors provide an updated and concise review of the current indications and contraindications for medial UKA using scientifically based consensus-building methodology. (Journal of Surgical Orthopaedic Advances 24(4):252–256, 2015) Key words: contraindications, indications, unicompartmental arthroplasty

Ulnocarpal impaction (UCI) syndrome is a well-recognized and relatively frequent cause of ulnar-sided wrist pain and limitation of motion. In the setting of negative or questionable negative radiographs and a strong clinical suspicion for UCI, magnetic resonance imaging (MRI) is helpful in detecting occult disease. Current MRI technology is capable of providing high-spatial-resolution images on multiple planes while manipulating contrast to highlight different tissue types. However, imaging of the triangular fibrocartilage complex has been challenging because of the small and complex components of this structure. In this article, the stages of UCI are discussed with illustrations of the spectrum of MRI findings using Palmer classification as a guideline. (Journal of Surgical Orthopaedic Advances 24(4):257–262, 2015) Key words: TFCC, ulnocarpal impingement, ulnolunate abutment, wrist ligaments, wrist MRI

Postoperative pain control after total knee arthroplasty is a major contributing factor to patient satisfaction, rehabilitation, and length of stay. Current clinical practice guidelines recommend a multimodal pain management protocol, including the use of regional anesthesia. Periarticular injection (PAI) has been shown to provide excellent pain relief after total knee arthroplasty. Recently, liposomal bupivacaine has been introduced as a long-acting alternative to traditional local anesthetics, such as bupivacaine or ropivacaine. Liposomal bupivacaine is a sustained-release preparation designed to provide local analgesia up to 72 hours after initial application. The efficacy of PAI relies significantly on a meticulous, systematic injection technique. This article details recommendations for solution preparation and injection during total knee arthroplasty on the basis of the experience of a high-volume orthopaedic reconstruction service. (Journal of Surgical Orthopaedic Advances 24(4):263–266, 2015) Key words: Exparel, liposomal bupivacaine, multimodal analgesia, periarticular injection, total knee arthroplasty