The economic implications of a multimodal analgesic regimen for patients undergoing major orthopedic surgery: a comparative study of direct costs

The evolution of anesthetic management for total knee arthroplasty (TKA) patients: A hospital network experience

Introduction

In the face of an ongoing opioid epidemic and an aging population, the utilization of a successful multimodal pain regimen in patients undergoing total knee arthroplasty (TKA) is vital. This study looks to explore the effect of different types of anesthesia in addition to a multimodal pain regimen on post-operative outcomes after undergoing TKA.

Materials and methods

From January 2016 to December 2022, 783 charts of patients undergoing an elective TKA were reviewed. Patients undergoing primary, isolated, and unilateral TKA procedures were included. Patients were grouped into three study arms: 1) general anesthesia (GA); 2) general anesthesia with a local anesthetic adductor canal block (GA + ACB); 3) spinal anesthesia with local anesthetic adductor canal block (SA + ACB). Patients who received other anesthesia types or received ACB utilizing liposomal bupivacaine were excluded.

Results

Of the 420 included patients, 63 patients received GA, 148 GA + ACB, and 209 SA + ACB. Patients in the SA + ACB group had a shorter LOS compared to both the GA + ACB and GA groups (p < 0.01. The SA + ACB group had the lowest daily average OME requirement (p < 0.01). Finally, patients in the SA + ACB group had the lowest average total cost of $11,683.91 (p < 0.01).

Discussion

Spinal anesthesia with adductor canal block is effective in decreasing opioid usage and improving postoperative outcomes after TKA. Surgeons and anesthesiologists should look to utilize this anesthetic option along with a multimodal regimen when deciding how to best manage postoperative pain after TKA procedures.

Level of evidence

Level III.

Multimodal postoperative analgesia with transdermal buprenorphine is a safe option in arthroscopic rotator cuff repair

BACKGROUND

Arthroscopic rotator cuff repairs are associated with moderate-to-severe pain. Opioids are not the first line for postsurgical pain control due to their potential misuse and side effects. Transdermal buprenorphine represents an alternative for multimodal postoperative pain control.

METHODS

This was a single-centre, prospective longitudinal exploratory study of patients undergoing arthroscopic rotator cuff repairs managed with multimodal analgesia with transdermal buprenorphine. Patients were followed-up by telephone at eight time points, assessing pain levels, rescue analgesics requirement and side effects.

FINDINGS

Twenty-five patients with an average age of 63.4 ± 8.2 were included. Fourteen patients were ⩾65 years. Pain levels were similar among age groups at all time points, with no pain or mild pain (visual analogue scale 1-4) in most patients. The most frequent side effects were dizziness and somnolence.

CONCLUSION

Transdermal buprenorphine provided a sustained analgesic effect after an arthroscopic rotator cuff repair during the acute postsurgical period. It showed a similar safety profile among younger and older patients.

Implementation of the Fast-track Protocol for Total Hip Arthroplasty in a Public Hospital in the State of São Paulo - Brazil

Objective  Evaluate the results of the implementation of the Fast Track Protocol (FTP), a medical practice based on scientific evidence, for elective total hip arthroplasty surgery, mainly comparing the National Average Hospital Admission Rate of 7.1 days. Methods  98 patients who underwent elective total hip arthroplasty surgery via the direct anterior approach, anterolateral approach and posterior approach were included in the FTP from December 2018 to March 2020, being followed up preoperatively, intraoperatively and immediately postoperatively. Results  The average length of hospital stay was 2.8 days, being 2.1 days for the direct anterior approach, 3.0 days for the anterolateral access approach and 4.1 days for the posterior access approach. The average surgery time was 90 minutes, 19 (19.39%) of the patients were referred to the ICU in the postoperative period, however, none of them underwent surgery using the direct anterior approach. We had no cases of deep vein thrombosis (DVT), pulmonary embolism (PTE) or neurological injury, 19 (19.39%) patients had postoperative bleeding requiring dressing change, 4 (4.08%) needed blood transfusion, 2 (2.04%) patients had implant instability, 1 (1.02%) patient had a fracture during surgery and 1 (1.02%) patient died of cardiac complications. Conclusion  FTP may be a viable alternative to reduce the length of stay and immediate postoperative complications for elective total hip arthroplasty surgery decreasing the length of stay of patients by 2 to 3 times when compared to the national average of 7.1 days.

Postoperative Pain Control Following Shoulder Arthroplasty: Rethinking the Need for Opioids

The use of opioid pain medication regimens to control perioperative pain has led to significant patient and societal consequences. There are several alternative, opioid-sparing and opioid-minimizing pain regimens that have been shown to provide equal, if not superior, pain relief with fewer secondary consequences. This article provides an in-depth review of the current evidence regarding efficacy, safety, and feasibility of a perioperative opioid-sparing clinical pathway for patients undergoing shoulder arthroplasty.

Duration of Care and Operative Time Are the Primary Drivers of Total Charges After Ambulatory Hip Arthroscopy: A Machine Learning Analysis

PURPOSE

To develop a machine learning algorithm to predict total charges after ambulatory hip arthroscopy and create a risk-adjusted payment model based on patient comorbidities.

METHODS

A retrospective review of the New York State Ambulatory Surgery and Services database was performed to identify patients who underwent elective hip arthroscopy between 2015 and 2016. Features included in initial models consisted of patient characteristics, medical comorbidities, and procedure-specific variables. Models were generated to predict total charges using 5 algorithms. Model performance was assessed by the root-mean-square error, root-mean-square logarithmic error, and coefficient of determination. Global variable importance and partial dependence curves were constructed to show the impact of each input feature on total charges. For performance benchmarking, the best candidate model was compared with a multivariate linear regression using the same input features.

RESULTS

A total of 5,121 patients were included. The median cost after hip arthroscopy was $19,720 (interquartile range, $12,399-$26,439). The gradient-boosted ensemble model showed the best performance (root-mean-square error, $3,800 [95% confidence interval, $3,700-$3,900]; logarithmic root-mean-square error, 0.249 [95% confidence interval, 0.24-0.26]; R² = 0.73). Major cost drivers included total hours in facility less than 12 or more than 15, longer procedure time, performance of a labral repair, age younger than 30 years, Elixhauser Comorbidity Index (ECI) of 1 or greater, African American race, residence in extreme urban and rural areas, and higher household and neighborhood income.

CONCLUSIONS

The gradient-boosted ensemble model effectively predicted total charges after hip arthroscopy. Few modifiable variables were identified other than anesthesia type; nonmodifiable drivers of total charges included duration of care less than 12 hours or more than 15 hours, operating room time more than 100 minutes, age younger than 30 years, performance of a labral repair, and ECI greater than 0. Stratification of patients based on the ECI highlighted the increased financial risk borne by physicians via flat reimbursement schedules given variable degrees of comorbidities.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Postoperative analgesia and opioid use following hip arthroscopy with ultrasound-guided quadratus lumborum block: a randomized controlled double-blind trial

Objective

To investigate the postoperative analgesic effect of ultrasound-guided quadratus lumborum block (QLB) in patients undergoing arthroscopic hip surgery.

Methods

Patients who were scheduled to undergo elective arthroscopic hip surgery were randomly assigned to the QLB (Q) or control (C) group (n = 40 each). After general anesthesia induction, unilateral QLB was performed under ultrasound guidance in the Q group. The amount of opioid use via patient-controlled analgesia (PCA) and the resting and movement pain visual analog scale (VAS) scores when the patient left the postanesthesia care unit (PACU) and 4, 8, 12, and 24 hours after surgery were recorded. Postoperative complications were recorded for both groups.

Results

At 24 hours post-surgery, opioid consumption amounts via PCA (48.4 [48.1–48.6] mL) in the Q group were significantly lower compared with the C group (52.0 [51.0–53.8] mL). A significant reduction in opioid consumption was observed between the two groups at each time point. Resting and movement VAS scores at each time point were significantly lower in the Q compared with the C group.

Conclusions

Hip arthroscopy patients who received QLB and general anesthesia in combination had less pain and a lower opioid requirement within 24 hours postoperatively.

Poor nutritional status correlates with mortality and worse postoperative outcomes in patients with femoral neck fractures

AIMS

Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes.

METHODS

A total of 1,199 patients with femoral neck fractures presented to a large UK teaching hospital over a three-year period. All patients had nutritional assessments performed using the Malnutrition Universal Screening Tool (MUST). Malnutrition risk was compared to mortality, length of hospital stay, and discharge destination using logistic regression. Adjustments were made for covariates to identify whether malnutrition risk independently affected these outcomes.

RESULTS

Inpatient mortality was 5.2% (35/678) in the group at low risk of malnutrition, 11.3% (46/408) in the medium-risk group, and 17.7% (20/113) in the high-risk group. Multivariate analysis showed each categorical increase in malnutrition risk independently predicted inpatient mortality with an odds ratio (OR) of 1.59 (95% confidence interval (CI) 1.14 to 2.21; p = 0.006). An increased mortality rate persisted at 120 days post-injury (OR 1.64, 95% CI 1.20 to 2.22; p = 0.002). There was a stepwise increase in the proportion of patients discharged to a residence offering a greater level of supported living. Multivariate analysis produced an OR of 1.34 (95% CI 1.03 to 1.75; p = 0.030) for each category of MUST score. Median length of hospital stay increased with a worse MUST score: 13.9 days (interquartile range (IQR) 8.2 to 23.8) in the low-risk group; 16.6 days (IQR 9.0 to 31.5) in the medium-risk group; and 22.8 days (IQR 10.1 to 41.1) in the high-risk group. Adjustment for covariates revealed a partial correlation coefficient of 0.072 (p = 0.008).

CONCLUSION

A higher risk of malnutrition independently predicted increased mortality, length of hospital stay, and discharge to a residence offering greater supported living after femoral neck fracture. Cite this article: Bone Joint J 2021;103-B(1):164-169.

Effect of Multimodal Drugs Infiltration on Postoperative Pain in Split Laminectomy of Lumbar Spine: A Randomized Controlled Trial

STUDY DESIGN

A randomized, double-blinded controlled trial.

OBJECTIVE

This study tested the effect of single-dose wound infiltration with multiple drugs for pain management after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Patients undergoing spine surgery often experience severe pain especially in early postoperative period. We hypothesized that intraoperative wound infiltration with multiple drugs would improve outcomes in lumbar spine surgery.

METHODS

Fifty-two patients who underwent one to two levels of spinous process splitting laminectomy of lumbar spine, were randomized into two groups. Infiltration group received intraoperative wound infiltration of local anesthetics, morphine sulfate, epinephrine, and nonsteroidal anti-inflammatory drugs at the end of surgery, and received patient-controlled analgesia (PCA) postoperatively. The control group received only PCA postoperatively. The primary outcome measures were amount of morphine consumption and visual analogue scale (VAS) for pain. The secondary outcome measures were Oswestry Disability Index (ODI), Roland-Morris Low Back Pain and Disability Questionnaire (RMDQ), patient satisfaction, length of hospital stay, and side effects.

RESULTS

A total of 49 patients (23 patients for local infiltration group, and 26 patients for control group) were analyzed. There were statistically significant [P < 0.001, the effect size -5.0, 95% CI (-6.1, -3.9)] less morphine consumptions in the local infiltration group than the control group during the first 12 hours, 12 to 24 hours, and 24 to 48 hours after surgery. The VAS of postoperative pain reported by patients at rest and during motion was significantly lower in the local infiltration group than the control group at all assessment times (P < 0.001). The effect size of VAS of postoperative pain at rest and during motion were -2.0, 95% CI (-2.5, -1.4) and -2.0, 95% CI (-2.6, -1.4) respectively. ODI and RMDQ at 2 week and 3 month follow-ups in both groups had significant improvement from baseline (P < 0.001). No significant differences were found between groups (P = 0.262 for ODI and P = 0.296 for RMDQ). There were no significant differences of patient satisfaction, length of stay, and side effects between both groups (P = 0.256, P = 0.262, P = 0.145 respectively).

CONCLUSION

Intraoperative wound infiltration with multimodal drugs reduced postoperative morphine consumption, decreased pain score with no increased side effects.

LEVEL OF EVIDENCE

1.

Evolving the management of acute perioperative pain towards opioid free protocols: a narrative review

Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the US, with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.Methods: Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid-free/opioid-sparing strategies published in English.Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery, as well as reduced healthcare utilization costs, are also discussed, along with challenges facing the implementation of such strategies.Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA is still in early stages and will require personalization and better management of patient expectations.

Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury

PURPOSE

We aimed to produce comprehensive guidelines and recommendations that can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury.

METHODS

A panel of 15 members with expertise in orthopaedic trauma, pain management, or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The methods described by the Grading of Recommendations Assessment, Development, and Evaluation Working Group were applied to each recommendation. The guideline was submitted to the Orthopaedic Trauma Association (OTA) for review and was approved on October 16, 2018.

RESULTS

We present evidence-based best practice recommendations and pain medication recommendations with the hope that they can be utilized by orthopaedic practices as well as other specialties to improve the management of acute pain following musculoskeletal injury. Recommendations are presented regarding pain management, cognitive strategies, physical strategies, strategies for patients on long term opioids at presentation, and system implementation strategies. We recommend the use of multimodal analgesia, prescribing the lowest effective immediate-release opioid for the shortest period possible, and considering regional anesthesia. We also recommend connecting patients to psychosocial interventions as indicated and considering anxiety reduction strategies such as aromatherapy. Finally, we also recommend physical strategies including ice, elevation, and transcutaneous electrical stimulation. Prescribing for patients on long term opioids at presentation should be limited to one prescriber. Both pain and sedation should be assessed regularly for inpatients with short, validated tools. Finally, the group supports querying the relevant regional and state prescription drug monitoring program, development of clinical decision support, opioid education efforts for prescribers and patients, and implementing a department or organization pain medication prescribing strategy or policy.

CONCLUSIONS

Balancing comfort and patient safety following acute musculoskeletal injury is possible when utilizing a true multimodal approach including cognitive, physical, and pharmaceutical strategies. In this guideline, we attempt to provide practical, evidence-based guidance for clinicians in both the operative and non-operative settings to address acute pain from musculoskeletal injury. We also organized and graded the evidence to both support recommendations and identify gap areas for future research.

Medication, equipment, and supply costs for common interventions providing extended post-surgical analgesia following total knee arthroplasty in US hospitals

AIMS

To estimate the cost to hospitals of materials (i.e. medications, equipment, and supplies) required to administer common interventions for post-surgical analgesia after total knee arthroplasty (TKA), including single-injection peripheral nerve block (sPNB), continuous peripheral nerve block (cPNB), periarticular infiltration of multi-drug cocktails, continuous epidural analgesia, intravenous patient-controlled analgesia (IV PCA), and local infiltration of bupivacaine liposome injectable suspension (BLIS).

MATERIALS AND METHODS

This analysis was conducted using a mixed methods approach combining published literature, publicly available data sources, and administrative data, to first identify the materials required to administer these interventions, and then estimate the cost to the hospital of those materials. Medication costs were estimated primarily using the Wholesale Acquisition Costs (WAC), the cost of reusable equipment was obtained from published sources, and costs for disposable supplies were obtained from the US Government Services Administration (GSA) database. Where uncertainty existed about the technique used when administering these interventions, costs were calculated for multiple scenarios reflecting different assumptions.

RESULTS

The total cost of materials (i.e. medications, equipment, and supplies) required to provide post-surgical analgesia was $41.88 for sPNB with bupivacaine; $756.57 for cFNB with ropivacaine; $16.38 for periarticular infiltration with bupivacaine, morphine, methylprednisolone, and cefuroxime; $453.84 for continuous epidural analgesia with fentanyl and ropivacaine; $178.94 for IV PCA with morphine; and $319.00 for BLIS.

LIMITATIONS

This analysis did not consider the cost of healthcare providers required to administer these interventions. In addition, this analysis focused on the cost of materials and, therefore, did not consider aspects of relative efficacy or safety, or how the choice of intervention for post-surgical analgesia might impact outcomes such as length of stay, re-admissions, discharge status, adverse events, or total hospitalization costs.

CONCLUSIONS

This study provided an estimate of the costs to hospitals for materials required to administer commonly used interventions for post-surgical analgesia after TKA.

Continuous Posterior Lumbar Plexus Nerve Block Versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Total Hip Arthroplasty: A Three-Arm Randomized Clinical Trial

BACKGROUND

Debate surrounds the issue of whether peripheral nerve blockade or periarticular infiltration (PAI) should be employed within a contemporary, comprehensive multimodal analgesia pathway for total hip arthroplasty. We hypothesized that patients treated with a continuous posterior lumbar plexus block (PNB) would report less pain and consume less opioid medication than those treated with PAI.

METHODS

This investigator-initiated, independently funded, 3-arm randomized clinical trial (RCT) performed at a single high-volume institution compared postoperative analgesia interventions for elective, unilateral primary total hip arthroplasty: (1) PNB; (2) PAI with ropivacaine, ketorolac, and epinephrine (PAI-R); and (3) PAI with liposomal bupivacaine, ketorolac, and epinephrine (PAI-L) using computerized randomization. The primary outcome was maximum pain during the morning (06:00 to 12:00) of the first postoperative day (POD) on an ascending numeric rating scale (NRS) from 0 to 10. Pairwise treatment comparisons were performed using the rank-sum test, with a p value of <0.017 indicating significance (Bonferroni adjusted). A sample size of 150 provided 80% power to detect a difference of 2.0 NRS units.

RESULTS

We included 159 patients (51, 54, and 54 patients in the PNB, PAI-R, and PAI-L groups, respectively). No significant differences were found with respect to the primary end point on the morning of the first POD (median, 3.0, 4.0, and 3.0, respectively; p > 0.033 for all). Opioid consumption was low and did not differ across groups at any intervals. Median maximum pain on POD 1 was 5.0, 5.5, and 4.0, respectively, and was lower for the PAI-L group than for the PAI-R group (p = 0.006). On POD 2, maximum pain (median, 3.5, 5.0, and 3.5, respectively) was lower for the PNB group (p = 0.014) and PAI-L group (p = 0.016) compared with the PAI-R group. The PAI-L group was not significantly different from the PNB group with respect to any outcomes: postoperative opioid use including rescue intravenous opioid medication, length of stay, and hospital adverse events, and 3-month follow-up data including any complication.

CONCLUSIONS

In this RCT, we found a modest improvement with respect to analgesia in patients receiving PNB compared with those receiving PAI-R, but not compared with those who had PAI-L. Secondary analyses suggested that PNB or PAI-L provides superior postoperative analgesia compared with PAI-R. For primary total hip arthroplasty, a multimodal analgesic regimen including PNB or PAI-L provides opioid-limiting analgesia.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Combined Sciatic and Lumbar Plexus Nerve Blocks for the Analgesic Management of Hip Arthroscopy Procedures: A Retrospective Review

Hip arthroscopy is a minimally invasive alternative to open hip surgery. Despite its minimally invasive nature, there can still be significant reported pain following these procedures. The impact of combined sciatic and lumbar plexus nerve blocks on postoperative pain scores and opioid consumption in patients undergoing hip arthroscopy was investigated. A retrospective analysis of 176 patients revealed that compared with patients with no preoperative peripheral nerve block, significant reductions in pain scores to 24 hours were reported and decreased opioid consumption during the post anesthesia care unit (PACU) stay was recorded; no significant differences in opioid consumption out to 24 hours were discovered. A subgroup analysis comparing two approaches to the sciatic nerve block in patients receiving the additional lumbar plexus nerve block failed to reveal a significant difference for this patient population. We conclude that peripheral nerve blockade can be a useful analgesic modality for patients undergoing hip arthroscopy.

Hospitalization Costs for Patients Undergoing Orthopedic Surgery Treated With Intravenous Acetaminophen (IV-APAP) Plus Other IV Analgesics or IV Opioid Monotherapy for Postoperative Pain

INTRODUCTION

To assess the impact on hospitalization costs of multimodal analgesia (MMA), including intravenous acetaminophen (IV-APAP), versus IV opioid monotherapy for postoperative pain management in patients undergoing orthopedic surgery.

METHODS

Utilizing the Truven Health MarketScan® Hospital Drug Database (HDD), patients undergoing total knee arthroplasty (TKA), total hip arthroplasty (THA), or surgical repair of hip fracture between 1/1/2011 and 8/31/2014 were separated into postoperative pain management groups: MMA with IV-APAP plus other IV analgesics (IV-APAP group) or an IV opioid monotherapy group. All patients could have received oral analgesics. Baseline characteristics and total hospitalization costs were compared. Additionally, an inverse probability treatment weighting [IPTW] with propensity scores analysis further assessed hospitalization cost differences.

RESULTS

The IV-APAP group (n = 33,954) and IV opioid monotherapy group (n = 110,300) differed significantly (P < 0.0001) across baseline characteristics, though the differences may not have been clinically meaningful. Total hospitalization costs (mean ± standard deviation) were significantly lower for the IV-APAP group than the IV opioid monotherapy group (US$12,540 ± $9564 vs. $13,242 ± $35,825; P < 0.0001). Medical costs accounted for $701 of the $702 between-group difference. Pharmacy costs were similar between groups. Results of the IPTW-adjusted analysis further supported the statistically significant cost difference.

CONCLUSIONS

Patients undergoing orthopedic surgery who received MMA for postoperative pain management, including IV-APAP, had significantly lower total costs than patients who received IV opioid monotherapy. This difference was driven by medical costs; importantly, there was no difference in pharmacy costs. Generalizability of the results may be limited to patients admitted to hospitals similar to those included in HDD. Dosing could not be determined, so it was not possible to quantify utilization of IV-APAP or ascertain differences in opioid consumption between the 2 groups. This study did not account for healthcare utilization post-discharge.

Postoperative pain control after arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair (ARCR) can provide excellent clinical results for patients who fail to respond to conservative management of symptomatic rotator cuff tears. ARCR, however, can be associated with severe postoperative pain and discomfort that requires adequate analgesia. As ARCR continues to shift toward being performed as an outpatient procedure, it is incumbent on physicians and ambulatory surgical centers to provide appropriate pain relief with minimal side effects to ensure rapid recovery and safe discharge. Although intravenous and oral opioids are the cornerstone of pain management after orthopedic procedures, they are associated with drowsiness, nausea, vomiting, and increased length of hospital stay. As health care reimbursements continue to become more intimately focused on quality, patient satisfaction, and minimizing of complications, the need for adequate pain control with minimal complications will continue to be a principal focus for providers and institutions alike. We present a review of alternative modalities for pain relief after ARCR, including cryotherapy, intralesional anesthesia, nerve blockade, indwelling continuous nerve block catheters, and multimodal anesthesia. In choosing among these modalities, physicians should consider patient- and system-based factors to allow the efficient delivery of analgesia that optimizes recovery and improves patient satisfaction.

Nursing strategies to reduce length of stay for persons undergoing total knee replacement: integrative review of key variables

Decreasing the length of stay for persons undergoing total knee replacement surgery can improve patient and organizational outcomes while reducing health care costs. This integrative review examined selected nurse-driven variables that assist the interdisciplinary team to reduce length of stay. Findings suggest that a targeted clinical pathway including comprehensive preoperative patient education, physical therapy on the day of surgery, multimodal pain control, and proactive discharge planning may provide the best practice with this patient population.

Examining the Role of Perioperative Nerve Blocks in Hip Arthroscopy: A Systematic Review

PURPOSE

This systematic review examined the efficacy of perioperative nerve blocks for pain control after hip arthroscopy.

METHODS

The databases Embase, PubMed, and Medline were searched on June 2, 2015, for English-language studies that reported on the use of perioperative nerve blocks for hip arthroscopy. The studies were systematically screened and data abstracted in duplicate.

RESULTS

Nine eligible studies were included in this review (2 case reports, 2 case series, 3 non-randomized comparative studies, and 2 randomized controlled trials). In total, 534 patients (534 hips), with a mean age of 37.2 years, who underwent hip arthroscopy procedures were administered nerve blocks for pain management. Specifically, femoral (2 studies), fascia iliaca (2 studies), lumbar plexus (3 studies), and L1 and L2 paravertebral (2 studies) nerve blocks were used. All studies reported acceptable pain scores after the use of nerve blocks, and 4 studies showed significantly lower postoperative pain scores acutely with the use of nerve blocks over general anesthesia alone. The use of nerve blocks also resulted in a decrease in opioid consumption in 4 studies and provided a higher level of patient satisfaction in 2 studies. No serious acute complications were reported in any study, and long-term complications from lumbar plexus blocks, such as local anesthetic system toxicity (0.9%) and long-term neuropathy (2.8%), were low in incidence.

CONCLUSIONS

The use of perioperative nerve blocks provides effective pain management after hip arthroscopy and may be more effective in decreasing acute postoperative pain and supplemental opioid consumption than other analgesic techniques.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I to Level IV studies.

Improving total knee arthroplasty perioperative pain management using a periarticular injection with bupivacaine liposomal suspension

Patients undergoing total knee arthroplasty (TKA) report low satisfaction with postoperative pain control. The purpose of this study is to examine if there is a difference in post-operative pain for TKA patients without femoral nerve block receiving an intra-operative pericapsular injection of bupivacaine liposome suspension (EXPAREL; Pacira Pharmaceuticals, Inc., San Diego, California) versus a concentrated multi drug cocktail. Seventy TKA patients were randomly assigned to either the bupivacaine liposome or the multi-drug cocktail. Post-operative pain scores, morphine sulfate equivalence consumption values, adverse events, and overall pain control satisfaction scores were collected. Patients reported significantly higher pain level for the cocktail group on post-op day 1 (p < .05) and post-op day 2 (p < .01) versus the bupivacaine liposome group. This same trend was found for morphine sulfate equivalence consumption in the PACU (p < .01) and post-op day 2 (p < .01). Higher satisfaction in pain control (p < .001) and overall experience (p < .01) was also found in the bupivacaine liposome group. Finally, significantly more adverse events were found in the multi-drug group versus the bupivacaine liposome group (p < .05). The study findings demonstrated a non-inferior difference, albeit not a clinically significant difference, in patient-perceived pain scores, morphine sulfate equivalence consumption, adverse events, and overall satisfaction.

Transformation of anesthesia for ambulatory orthopedic surgery: A mixed-methods study of a diffusion of innovation in healthcare

INTRODUCTION

To provide insight into how an innovation in healthcare is implemented and diffused, we studied the transition from routine use of general anesthesia to peripheral nerve blocks (PNBs) for ambulatory orthopedic extremity surgery. Rogers' diffusion of innovations (DOI) theory was used as our theoretical framework. We identified themes that would be helpful for others attempting to diffuse innovations into healthcare settings.

MATERIAL AND METHODS

A mixed quantitative and qualitative methodology was used. We retrospectively reviewed operative and anesthesia records of patients who underwent ambulatory repair of distal radius fractures or arthroscopic knee meniscus procedures from 1998 to 2012 to identify whether general anesthetics or PNBs were used and the time course of the innovation. We interviewed orthopedic surgeons, anesthesiologists, and a nursing administrator working in the ambulatory surgery unit during the innovation to identify key themes associated with the adoption of PNBs.

RESULTS

From 2003 to 2012, use of PNBs increased from less than 10% to 70% of cases studied. The adoption timeframe followed an S-shaped curve. Key themes included improved safety, quality, efficiency, physician leadership and trust, organizational structure, and technological change. The innovation involved an optional decision-making process and took root in a satellite facility and generally fit with Rogers DOI theory.

CONCLUSIONS

The adoption and diffusion of PNBs provides a useful model for understanding innovations with optional decision-making in healthcare. Critical elements in our case were the characteristics of the innovation, which facilitated the decision-making process, and the positioning of the innovation in a peripheral structure away from core clinical facilities.

Cyclo-oxygenase-2 inhibition and endothelium-dependent vasodilation in younger vs. older healthy adults

AIM

A major feature of endothelial dysfunction is reduced endothelium-dependent vasodilation, which in ageing may be due to decreased production of endothelial prostacyclin, or nitric oxide (NO), or both.

METHOD

We tested this hypothesis in 12 younger (age 18-38 years, six women) and 12 older healthy adults (age 55-73 years, six post-menopausal women). Endothelium-dependent vasodilation was assessed by the forearm vascular conductance (FVC) response to intra-arterial acetylcholine (ACh) (0.5, 1.0, 2.0, 4.0 μg dl(-1) forearm tissue min(-1) ) before and 90 min after inhibition of the enzyme cyclo-oxygenase-2 (COX-2) with oral celecoxib (400 mg), followed by the addition of endothelial NO synthase inhibition with intra-arterial N(G) -monomethyl-l arginine acetate (L-NMMA).

RESULTS

Ageing was associated with a significantly reduced FVC response to ACh (P = 0.009, age-by-dose interaction; highest dose FVC ± SEM in ageing: 11.2 ± 1.4 vs. younger: 17.7 ± 2.4 units, P = 0.02). Celecoxib did not reduce resting FVC or the responses to ACh in any group. L-NMMA significantly reduced resting FVC and the responses to ACh in all groups, and absolute FVC values following L-NMMA were similar between groups.

CONCLUSION

In healthy normotensive younger and older adults, there is minimal contribution of prostacyclin to ACh-mediated vasodilation, yet the NO component of vasodilation is reduced with ageing. In the clinical context, these findings suggest that acute administration of medications that inhibit prostacyclin (i.e. COX-2 inhibitors) evoke modest vascular consequences in healthy persons. Additional studies are necessary to test whether chronic use of COX-2 medications reduces endothelium dependent vasodilation in older persons with or without cardiovascular risk factors.

Prevalence and Costs of Rehabilitation and Physical Therapy After Primary TJA

This study evaluated the trends in discharge patterns and the prevalence and cost of post-discharge PT. The 5% Medicare database (1997-2010) was used to identify 50,886 primary THA and 107,675 TKA patients. More than 50% of patients were discharged from hospital to an inpatient facility. There were an increase in discharges to skilled nursing units and a reduced rate to rehabilitation facilities. In contrast to hospital, surgeon reimbursement, and implant costs, the average annual PT cost per patient rose through the study period. Approximately 25% of PT costs were used on less common modalities. PT costs more than $648 million a year. With the increased pressure to control costs for primary TJA, these patterns may change unless PT effectiveness can be demonstrated.

Optimizing perioperative management of total joint arthroplasty

Clinical pathways for total joint arthroplasty have been shown to reduce costs and significantly impact perioperative outcomes mainly through reducing provider variability. Effective clinical pathways link evidence to individual practice and balance costs with local experience, outcomes, and access to resources for responsible perioperative management. Common components of clinical pathways with major impact on perioperative outcomes are: 1) implementing pathways designed to include multimodal analgesia with regional anesthesia, 2) use of tranexamic acid to reduce blood loss, and 3) preconditioning followed by participation in early, accelerated rehabilitation programs to prevent postoperative complications related to immobility.

Which outcomes related to regional anesthesia are most important for orthopedic surgery patients?

An increasing body of evidence supports the benefits of regional anesthesia in orthopedic surgery. Compared with systemic anesthetic and analgesic approaches, these benefits include more focused and sustained pain control, less systemic side effects, improved patient comfort, earlier mobilization and hospital discharge, lower rates of advanced service requirements, and lower perioperative morbidity and mortality. However, there is discussion about the various outcomes as judged by patients and heath care practitioners. This article recapitulates the literature and presents an overview of endpoints.

Multimodal pain management in orthopedics: implications for joint arthroplasty surgery

Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.

Impact of a preemptive multimodal analgesia plus femoral nerve blockade protocol on rehabilitation, hospital length of stay, and postoperative analgesia after primary total knee arthroplasty: a controlled clinical pilot study

PURPOSE

To compare preemptive multimodal analgesia (PMMA) without femoral nerve blocks (FNB) to PMMA including FNB following total knee arthroplasty (TKA).

METHODS

In a prospective, controlled pilot study, subjects with noninflammatory arthritis undergoing TKA and a short postoperative stay received either PMMA + FNB (FNB group; n = 19) or PMMA only (PMMA group; n = 20). No preoperative group differences were noted. Evaluations occurred in hospital and at 2, 6, and 12 weeks postoperatively. The primary outcome (knee flexion) was measured on day two postoperatively. Rehabilitation indices, pain, analgesic use, and length of stay (LOS) were also measured.

RESULTS

All subjects completed the study. The only significant group differences were quadriceps motor blocks in the FNB group (P < 0.001). No significant differences were noted in ROM, pain levels, analgesic use, or hospital LOS.

CONCLUSION

Other than the quadriceps motor block, no group differences were noted; both achieved satisfactory analgesia. Best postoperative pain management strategies when following a short hospital stay program are still unclear.

Pain management in total joint arthroplasty: a historical review

Patients undergoing total hip and knee arthroplasty experience substantial and sustained postoperative pain. Inadequate analgesia may impede recovery and delay hospital discharge. Traditionally, postoperative analgesia following arthroplasty was provided by intravenous patient-controlled analgesia or epidural analgesia, but each technique has distinct advantages and disadvantages. Recently, peripheral nerve blockade of the lumbosacral plexus has emerged as an alternative analgesic approach. An increasing number of studies have reported multimodal analgesia featuring unilateral peripheral block provide pain relief and functional outcomes similar to that of continuous epidural and superior to systemic analgesia but with fewer side effects. This review discusses the indications, benefits, and side effects associated with conventional and innovative analgesic approaches to facilitate rehabilitation and improve outcome following total joint arthroplasty.