What Is the Role of a Periarticular Injection for Knee Arthroplasty Patients Receiving a Multimodal Analgesia Regimen Incorporating Adductor Canal and Infiltration Between the Popliteal Artery and Capsule of the Knee Blocks? A Randomized Blinded Placebo-Controlled Noninferiority Trial

BACKGROUND

Optimal analgesic protocols for total knee arthroplasty (TKA) patients remain controversial. Multimodal analgesia is advocated, often including peripheral nerve blocks and/or periarticular injections (PAIs). If 2 blocks (adductor canal block [ACB] plus infiltration between the popliteal artery and capsule of the knee [IPACK]) are used, also performing PAI may not be necessary. This noninferiority trial hypothesized that TKA patients with ACB + IPACK + saline PAI (sham infiltration) would have pain scores that were no worse than those of patients with ACB + IPACK + active PAI with local anesthetic.

METHODS

A multimodal analgesic protocol of spinal anesthesia, ACB and IPACK blocks, intraoperative ketamine and ketorolac, postoperative ketorolac followed by meloxicam, acetaminophen, duloxetine, and oral opioids was used. Patients undergoing primary unilateral TKA were randomized to receive either active PAI or control PAI. The active PAI included a deep injection, performed before cementation, of bupivacaine 0.25% with epinephrine, 30 mL; morphine; methylprednisolone; cefazolin; with normal saline to bring total volume to 64 mL. A superficial injection of 20 mL bupivacaine, 0.25%, was administered before closure. Control injections were normal saline injected with the same injection technique and volumes. The primary outcome was numeric rating scale pain with ambulation on postoperative day 1. A noninferiority margin of 1.0 was used.

RESULTS

Ninety-four patients were randomized. NRS pain with ambulation at POD1 in the ACB + IPACK + saline PAI group was not found to be noninferior to that of the ACB + IPACK + active PAI group (difference = 0.3, 95% confidence interval [CI], [-0.9 to 1.5], P = .120). Pain scores at rest did not differ significantly among groups. No significant difference was observed in opioid consumption between groups. Cumulative oral morphine equivalents through postoperative day 2 were 89 ± 40 mg (mean ± standard deviation), saline PAI, vs 73 ± 52, active PAI, P = .1. No significant differences were observed for worst pain, fraction of time in severe pain, pain interference, side-effects (nausea, drowsiness, itching, dizziness), quality of recovery, satisfaction, length of stay, chronic pain, and orthopedic outcomes.

CONCLUSIONS

For TKA patients given a comprehensive analgesic protocol, use of saline PAI did not demonstrate noninferiority compared to active PAI. Neither the primary nor any secondary outcomes demonstrated superiority for active PAI, however. As we cannot claim either technique to be better or worse, there remains flexibility for use of either technique.

Effectiveness of oral versus intravenous tranexamic acid in primary total hip and knee arthroplasty: a randomised, non-inferiority trial

BACKGROUND

Tranexamic acid (TXA) reduces rates of blood transfusion for total hip arthroplasty (THA) and total knee arthroplasty (TKA). Although the use of oral TXA rather than intravenous (i.v.) TXA might improve safety and reduce cost, it is not clear whether oral administration is as effective.

METHODS

This noninferiority trial randomly assigned consecutive patients undergoing primary THA or TKA under neuraxial anaesthesia to either one preoperative dose of oral TXA or one preoperative dose of i.v. TXA. The primary outcome was calculated blood loss on postoperative day 1. Secondary outcomes were transfusions and complications within 30 days of surgery.

RESULTS

Four hundred participants were randomised (200 THA and 200 TKA). The final analysis included 196 THA patients (98 oral, 98 i.v.) and 191 TKA patients (93 oral, 98 i.v.). Oral TXA was non-inferior to i.v. TXA in terms of calculated blood loss for both THA (effect size=-18.2 ml; 95% confidence interval [CI], -113 to 76.3; P<0.001) and TKA (effect size=-79.7 ml; 95% CI, -178.9 to 19.6; P<0.001). One patient in the i.v. TXA group received a postoperative transfusion. Complication rates were similar between the two groups (5/191 [2.6%] oral vs 5/196 [2.6%] i.v.; P=1.00).

CONCLUSIONS

Oral TXA can be administered in the preoperative setting before THA or TKA and performs similarly to i.v. TXA with respect to blood loss and transfusion rates. Switching from i.v. to oral TXA in this setting has the potential to improve patient safety and decrease costs.

Patient perceptions of pain management and opioid use prior to hip arthroplasty

OBJECTIVE

Qualitative assessment investigating patients' perceptions related to opioids including their role in pain control, risks, and handling and disposal prior to undergoing hip replacement.

DESIGN

A prospective, cross-sectional survey study.

SETTING

Large urban teaching hospital specializing in orthopedic surgery affiliated with Weill Cornell Medical College.

PARTICIPANTS

Patients aged 18-80, English-speaking, without recent or chronic opioid use, and planning to undergo primary total hip replacement. A total of 128 patients were enrolled and completed the study.

INTERVENTION

A 27-item interview evaluating perceptions on opioid-related -topics.

MAIN OUTCOME MEASURES

Responses to interview questions were documented by research assistant.

RESULTS

Most patients believe that there should be minimal or no pain with the use of opioids, though they also agree that opioids should be limited to pain that interferes with function or activity. Patients generally appreciate risks of addiction with opioids but are less familiar with risks associated with sleep apnea and sedatives. Minority of patients understand that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with opioids would effectively reduce pain. Majority of patients were unsure of how to properly store and dispose of opioids.

CONCLUSIONS

Qualitative assessment demonstrates that patients may benefit from education and discussion specifically about pain expectations, the role of opioids in treating pain, multimodal analgesia, and proper storage and disposal.

Effect of portable negative pressure units on expelled aerosols in the operating room environment

INTRODUCTION

Spontaneously breathing patients undergoing procedures under regional anesthesia can expose operating room personnel to infectious agents. The use of localized negative pressure within proximity of a patient's airway is expected to reduce the amount of bioaerosols dispersed particularly for anesthesia staff who are frequently near the patient's airway.

METHODS

In the experiment, aerosols were produced using a polydisperse aerosol generator with nebulized saline. A portable negative pressure unit was set up at set distances of 10 cm and 30 cm with the aim of reducing aerosol particle counts detected by a laser-based particle counter.

RESULTS

Without the portable negative pressure unit, the median concentration of 0.5 µm aerosols detected was 3128 (1533, 22832) particles/ft³/min. With the portable negative pressure unit 10 cm and 30 cm from the site of aerosol emittance, the median concentration compared with background concentration was -0.5 (-8, 8) particles/ft³/min and 398 (89, 1749) particles/ft³/min, respectively.

CONCLUSIONS

For particle concentrations of 0.5 µm, 0.7 µm, and 1.0 µm a significant amount of aerosol reduction was observed (p<0.001). Further experiments are warranted to assess the safety of staff when encountering a potentially infectious patient in the operating room.

Characterization of Patients with COVID-19 Admitted to a Community Hospital of East Harlem in New York City

Background

New York City was the epicenter for the coronavirus disease 2019 (COVID-19) in the United States. Accordingly, the aim of this study was to characterize the population of patients admitted with this condition to a community hospital in East Harlem located in the northeast part of the city.

Methods

A retrospective review of medical records of patients at least 18 years of age, admitted to the hospital with COVID-19 disease from March 14 to April 30 of 2020.

Results

Three hundred and seventy-one patients were identified. The majority was comprised of men. Obesity, hypertension, and hyperlipidemia were the most prevalent comorbidities. Most patients were treated with a combination of hydroxychloroquine, azithromycin, zinc, and vitamin C. Twenty-three percent of the patients died from the disease during the study period.

Conclusion

Morbidity and mortality were substantial in patients with COVID-19 admitted to a community hospital in East Harlem.

Adaptation, Implementation, and Evaluation of a Public Health Research Methods Training for Youth

Purpose: To adapt, implement, and evaluate a public health research methods training program for youth. The Community Research Fellows Training Program is an evidence-based public health research methods training program for adults (18 years and older). The Youth Research Fellows Training (YRFT) is an adaptation of this program for youth.

Methods: University faculty facilitate didactic training sessions and experiential small group activities in biweekly sessions conducted as part of an existing 4-week summer camp. Participants were African American girls (n=11) ranging from ages 10 to 14 years (most recent grade completed 4th–8th). To evaluate participant knowledge gain and satisfaction pre-tests were administered before each session, and post-test and evaluations were administered after each session. In addition, faculty completed web-based evaluation surveys on their experience teaching in the program.

Results: Mean and median post-test scores were higher than pre-test scores for most (6 of the 7) of the training sessions; one session had no difference in scores. Participants rated the sessions well, on average overall session ratings of 4.3–4.8 on a 5-point Likert scale. Faculty rated their experience teaching in the program as excellent or very good and would be willing to teach in the program again (n=7; 100%).

Conclusion: This pilot implementation of the YRFT program proved highly successful in terms of participant and faculty experience. The program evaluation demonstrates increased knowledge of public health research methods. This program has the potential to prepare youth to engage in public health research as partners not just participants.