Volume 25-4, Winter 2016

Postsurgical pain, like that associated with major upper extremity surgery, can be significant and usually require the use of opioid analgesics. However, opioids are associated with significant adverse effects, including respiratory depression, which often drive the use of multimodal therapy with nonopioid analgesics, including local and regional analgesia techniques. However, use of older local anesthetics provides a limited duration of analgesia. An innovative formulation of liposomal bupivacaine (Exparel), which is approved for surgical site infiltration, can provide a longer duration of analgesia. Because optimal pain relief relies on the success of the surgical site infiltration technique, a group convened to address best practices for periarticular injection techniques for shoulder surgery. This article reviews the neuroanatomy of the shoulder, recommends optimal solutions (i.e., analgesic cocktails) and volume for injection, and provides a detailed description of the infiltration technique to develop the best approach to periarticular injection for major shoulder surgery. (Journal of Surgical Orthopaedic Advances 25(4):204–208, 2016) Key words: analgesia, liposomal bupivacaine, periarticular infiltration, postsurgical pain management, shoulder surgery

Postoperative pain control following total joint arthroplasty results in improved patient mobilization, participation in physical therapy, and potentially reduced hospital costs. It was hypothesized that using a multimodal pain protocol focusing on periarticular injections including liposomal bupivacaine would have improved results when compared with a parenteral opioid-based regimen. The results showed a decrease in length of stay and rate of discharge to skilled nursing facilities with the implementation of a novel multimodal pain protocol. Furthermore, there was no change in patient satisfaction before and after the execution of the new protocol. It was concluded that using a multimodal pain protocol based on periarticular injections can lead to decreased length of stay and a decrease in transfer to skilled nursing facilities without a change in patient satisfaction. (Journal of Surgical Orthopaedic Advances 25(4):209–214, 2016) Key words: arthroplasty, liposomal bupivacaine, multimodal pain management, opioid, pain management, total hip replacement, total knee replacement

Opioids are frequently used as part of multimodal pain management protocols for knee arthroscopy; however, their use may be associated with opioid-related adverse events. The purpose of this study was to evaluate the risk of potential analgesic-related complications after knee arthroscopy using a nationally representative database. Using 2010–2012 Medicare claims data, patients undergoing knee arthroscopy procedures (including ligament repair, meniscectomy, and chondroplasty) were identified. The risk of complications related to typical modalities of analgesia, including opioids, within 90 days following surgery was assessed usingmultivariate Cox regression. Based on follow-up of 16,567 cases, respiratory complications (bradypnea, pulmonary insufficiency, asphyxia, and hypoxemia) were the most frequently diagnosed complications (n = 418; 2.52%), followed by postoperative nausea and vomiting (n = 174; 1.05%) and urinary retention complications (n = 166; 1.00%). Risk factors including older age, male gender, lower socioeconomic status, and a high number of comorbidities were associated with development of postsurgical complications. (Journal of Surgical Orthopaedic Advances 25(4):215–221, 2016) Key words: adverse event, knee arthroscopy, opioid, pain

The purpose of this study was to determine if periarticular injection (PAI) with liposomal bupivacaine cocktail has a synergistic effect on pain relief with a single-injection adductor canal block in knee arthroplasty. Three hundred thirty-three knee arthroplasties were divided into three groups. Group 1 received general anesthesia (GA) and liposomal bupivacaine PAI. Group 2 received GA, peripheral nerve block (PNB), and liposomal bupivacaine PAI. Group 3 received GA, PNB, and ‘‘plain’’ ropivacaine PAI. Remaining perioperative multimodal medications and therapies were identical. There were no statistically significant differences in average narcotic use between any groups on the day of surgery, postoperative day 1, or postoperative day 2. Group 3 had the lowest postoperative nausea. Group 2 had the least pruritis. The current study failed to demonstrate a decrease in narcotic consumption with the combination of liposomal bupivacaine PAI and PNB. This study supports previous studies demonstrating that liposomal bupivacaine PAI provides similar outcomes to PNB. (Journal of Surgical Orthopaedic Advances 25(4):222–226, 2016) Key words: Exparel, knee arthroplasty, liposomal bupivacaine, multimodal pain, periarticular injection, peripheral nerve block

The use of opioids in the United States has become an epidemic. Opioids have become frequently prescribed for arthritic pain in the hip and knee. The use of opioidsas first-round therapy for pain has been driven by several factors, including the health care providers’ lack of understanding that antiinflammatory medications are at least as effective as opioids, a patient’s expectation of complete pain relief on presentation to the emergency room or doctor’s office, and increasing importance placed on patient satisfaction. The harmful effects of opioids are observed after joint replacement with long-term use leading to worse results after joint replacement. Decreasing the amount of opioids used before surgery improves outcomes after surgery. The use of opioids may be modified before surgery to give better surgical results. The goal of this review is to determine how opioid medications should fit into the treatment of arthritis pain, learn the guidelines for their use in arthritis, and understand how to educate health care providers that opioid use is a modifiable risk factor. (Journal of Surgical Orthopaedic Advances 25(4):227–233, 2016) Key words: hip arthroplasty, knee arthroplasty, modifiable risk factor, opioid, pain

Opioid misuse has been linked to patient health literacy. This study aimed to estimate the prevalence of low health literacy in a sample of orthopaedic patients on opioids. Data were extracted from an electronic medical record database using queries that included an 8-month time frame, active status in an orthopaedic clinic, ICD-10 codes for opioids, and health literacy screening results. In the study sample of 8963 orthopaedic patients, 7103 had opioids in their current chart. Of those patients with opioids in their chart, 1547 had inadequate health literacy as measured by a validated health literacy screening question. Because approximately 22% of orthopaedic patients on opioids may also be at high risk for low health literacy, practices should consider identifying these patients and following national recommendations to tailor patient education so that these patients can better understand the risks, benefits, and dosing of opioids. (Journal of Surgical Orthopaedic Advances 25(4):234–237, 2016) Key words: health literacy, opioids, orthopaedics

Orthopaedic surgeons often treat patients with chronic musculoskeletal pain. This musculoskeletal pain is increasingly being treated with opioid medications, contributing to the growing opioid epidemic in the United States. Opioid use and abuse before orthopaedic surgery are associated with worse clinical outcomes. This article reviews the risk factors for opioid use, misuse, and other behaviors in chronic pain patients, discusses the screening tools for opioid misuse in chronic pain patients, and provides recommendations for the orthopaedic surgeon’s role in managing these complicated patients. (Journal of Surgical Orthopaedic Advances 25(4):238–243, 2016) Key words: chronic pain, misuse, opioid, orthopaedic surgery, substance abuse

Femoroacetabular impingement (FAI) has gained considerable attention for the past 20 years and has been accepted as a predisposing factor for early osteoarthritis in young patients, particularly in the population participating in sports. Patients with FAI typically present with deep, intermittent groin discomfort during or after activities involving repetitive or persistent hip flexion. Symptomatic improvement can be achieved from arthroscopic debridement of unstable cartilage flaps, shaving of cartilage irregularities, and surgical correction of deformity of the femoral head–neck junction. Early and correct diagnosis of FAI has paramount importance for appropriate and timely management of the disorder before the development of osteoarthritis. Magnetic resonance (MR) imaging offers a noninvasive means of assessing the degree of damage to cartilage and adjacent labrum and bone and also evaluating the effectiveness of treatment. This article describes the morphologic types of FAI with emphasis on MR findings. (Journal of Surgical Orthopaedic Advances 25(4):244–249, 2016) Keywords: cam-type impingement, femoroacetabular impingement (FAI), hipMRI, labral tears, magnetic resonance imaging (MRI), pincer-type impingement