Introduction. Total hip arthroplasty (THA) candidates have received high doses of opioids within the perioperative period for the management of surgical pain. Healthcare systems have responded by improving opioid administration documentation and are now implementing opioid-sparing protocols (OSP) into THA integrated care pathways (ICP). Here we evaluate the effectiveness of a novel OSP in primary THA at out institution. Methods. Between January 2019 to April 2019, all patients undergoing primary THA were placed under a novel OSP (Table 1). Patient demographics, inpatient/surgical factors, and inpatient opiate administration events were collected. A historical 2:1 cohort was subsequently derived from patients undergoing THA between January 2018 to August 2018. Opiate administration events collected from our EDW were converted into Morphine Milligram Equivalences (MMEs) and transformed into average MME's per patient per 24-hour interval. Nursing documented visual analog scale (VAS) pain scores were also queried and averaged per patient per 12-hour interval. To assess immediate postoperative functional status, the validated Activity Measure for Post-Acute Care (AM-PAC) Short Forms tool was utilized. Results. 652 primary THAs had received our institution's OSP, and 1357 patients were utilized as our historical control. Age, gender, BMI, ASA physical status score, race, smoking status, marital status, surgical time, length of stay and discharge disposition were all similar between the two groups (Table 2). Compared to historical controls, OSP patients demonstrated significantly lower 24-hour interval opiate consumption at 0–24, 24–48 and 48–72 hours. Though VAS pain score variations reached statistical significance at various intervals, differences were not clinically relevant (Table 4). Lastly, OSP patients demonstrated significantly higher AM-PAC scores across all 6 functional domains (Table 5) and raw total scores within 24-hours of surgery completion. Discussion. Our OSP reduced opiate consumption by 26.50% while maintaining a comparable level of self-reported patient pain. Lower opiate utilization may also improve functional status in the immediate postoperative period. For any tables or figures, please contact the authors directly

Introduction. Postoperative nausea and vomiting (PONV) is a common occurrence following total joint arthroplasty, and can result in patient discomfort, delayed discharge, and decreased patient satisfaction. Carbohydrate loading as part of the Enhanced Recovery after Surgery (ERAS) protocol has gained popularity, and has been shown to minimize postoperative nausea, vomiting, pain, and lead to accelerated recovery and better overall outcome following abdominal surgery. This study aims to investigate the effects of preoperative carbohydrate-rich drinks on PONV following primary total knee arthroplasty (TKA). Methods. Patients undergoing primary TKA at one institution were enrolled randomly assigned to one of three groups: Group 1 received preoperative carbohydrate-rich drink, Group 2 received placebo water drink of similar appearance and taste, and Group 3 did not receive a drink (control). All healthcare personnel and patients (group 1 and 2) were blinded to group allocation. We compared rate of postoperative nausea, vomiting, length of stay (LOS), and opiate consumption (morphine equivalents, meq). We also reviewed visual analog scale (VAS) pain scores and serum glucose at 0–4 hours, 4–12 hours, and 12–24 hours postoperatively. Results. 229 eligible patients were enrolled and randomized. 79 patients were later excluded due to reasons precluding appropriate participation. 150 patients were included for final analysis, with 50 patients in Group 1, 48 patients in Group 2, and 52 patients in Group 3. The demographics and comorbid conditions known to increase risk of nausea and vomiting were similar between the groups. Rate of vomiting was not statistically significant across groups; group 1 (6%, 3/50), group 2 (13%, 6/48), group 3 (8%, 4/52), p=0.51. Rate of requiring antiemetic medication in group 1 (30%, 15/50) did not differ significantly from group 2 (27%, 13/48) and group 3 (40%, 21/52), p=0.32. Average LOS was not different in group 1 (32 hours) compared to group 2 (32.5 hours) and group 3 (32 hours), p=0.79. Average postoperative opiate consumption for group 1 (57.0 meq) was not statistically different from group 2 (61.3) or group 3 (61.0), p=0.91. Pain VAS scores and serum glucose measurements did not differ between groups for all three time periods (p>0.05). There was no difference in reported adverse events between groups. Conclusion. There appears to be no significant difference in PONV, antiemetic requirements, LOS, pain VAS scores, serum glucose measurements, and opiate consumption in patients receiving preoperative carbohydrate-rich drink prior to primary TKA. Preoperative carbohydrate-rich drinks are safe, however, their utility in the setting of arthroplasty does not yet demonstrate clinical benefit. Continued investigation is required. Summary. This is a prospective, randomized, double-blind, placebo-controlled trial investigating the effect of preoperative carbohydrate-rich drinks on postoperative nausea and vomiting following primary total knee arthroplasty. For any figures or tables, please contact authors directly

Purpose: TKR is a frequent surgical procedure with significant post-operative pain, requiring lot of opiates. Side effects are frequent and can modify post-operative rehabilitation. The goal of the study is to determine if the adjunction to a femoral block of intra-articular ropivacaïne can diminish the use of opiates and then gives better clinical results. The main clinical outcome is the opiate consumption at 48 h. Method: 80 consecutive patients admitted for TKR were randomized in the 2 groups (ropivacaïne vs control), surgeon, patient and clinical evaluator are blinded. Femoral block was performed and controlled for efficacy before surgery. Intra-articular injection of ropivacaïne or saline was delivered prior to wound closure with a catheter. Opiates were delivered with an ACP for 48 h. Rehabilitation was the same in the 2 groups. Results: We found no differences between the 2 groups in the opiate consumption at 24 and 48 h (p> 0,5). There was even an increase in opiate use in the experimental group, that couldn’t be explained by other factors (age, weight, surgical time, surgical tourniquet time, sex). There was no differences in ROM, hospital stay, side effects and EVA. Conclusion: There is no indication for the adjunction of intra-articular ropivacaïne to a femoral block after TKR. Other issues as combined blocks or other types of infiltrations (posterior capsule for example) could be considered in new trials to diminish pain after TKR

Background and objectives: Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts for TKR, but the efficacy of a sciatic nerve block as an adjunct to a femoral nerve block is controversial. The aim of this study was to compare femoral with femoral and sciatic nerve blocks in postoperative pain management of patients undergoing total knee arthroplasty (TKA). Methods: 42 patients were involved in the study. 20 patients received only a femoral nerve block, consisting of 20ml of 0.5% Chirocaine and 22 patients received femoral and sciatic nerve blocks, consisting of 20ml of 0.375% Chirocaine for the femoral nerve and 10ml of 0.5% Chirocaine for the sciatic nerve. The primary outcome measures used were visual analogue scale (VAS) scores for pain at 24 hours, 48 hours and 72 hours after the surgery, opiates consumption post-operatively and PCA use. The secondary outcomes were post-operative nausea and vomiting, sensory deficit, quadriceps contraction, straight leg raise, knee flexion, independent mobility and discharge from the hospital. Results: The results showed no difference in opiate consumption, PCA use, independent mobility and time of discharge from the hospital between the two groups. Conclusion: The study shows that the addition of a sciatic nerve block to the femoral nerve block does not provide additional benefits

Introduction. Opioids are an important component of multimodal analgesia, but improper utilization places patients at risk for overdose and addiction. The purpose of this randomized controlled trial is to determine whether the quantity of opioid pills prescribed at discharge is associated with the total amount of opioids consumed or unused by patients after total hip (THA) and knee (TKA) arthroplasty. Methods. 304 Opioid naïve patients undergoing THA or TKA were randomized to receive a prescription for either 30 or 90 5mg oxycodone immediate release (OxyIR) tablets at discharge. All patients received acetaminophen, meloxicam, tramadol and gabapentin perioperatively. Daily opioid consumption, reported in morphine equivalent dose (MED), number of unused OxyIR, and pain scores were calculated for 30 days postoperatively with a patient-completed medication diary. The number of OxyIR refills and total MED received were recorded for 90 days postoperatively. Power analysis determined that 141 patients per group were necessary to detect a 25% reduction in means in opiate consumption between groups. Statistical analysis involved t-test, rank sum, and chi-squared tests with alpha=0.05. Results. 161 Patients were randomized to receive 30 tablets and 143 to receive 90. In the first 30 days, the median number of unused OxyIR tablets was 15 in the 30 group versus 73 in the 90 group (p<0.0001). Within 90 days of discharge, 26.7% of the 30 group and 10.5% of the 90 group requested a refill (p<0.001), leading to a mean of 777.1 MED versus 1089.7 prescribed (p<0.0001). There was no difference between groups in mean MED consumed and pain scores within the first 30 days. Baseline demographics and outcome scores were similar between groups suggesting appropriate randomization. Conclusion. Prescribing a smaller number of opioids at the time of surgery is associated with equivalent pain scores and opioid consumption yet a significant reduction in unused narcotics

The direct superior approach (DSA) is a modification of the posterior approach (PA) that preserves the iliotibial band and short external rotators except for the piriformis or conjoined tendon during total hip arthroplasty (THA). The objective of this study was to compare postoperative pain, early functional rehabilitation, functional outcomes, implant positioning, implant migration, and complications in patients undergoing the DSA versus PA for THA. This study included 80 patients with symptomatic hip arthritis undergoing primary THA. Patients were prospectively randomised to receive either the DSA or PA for THA, surgery was undertaken using identical implant designs in both groups, and all patients received a standardized postoperative rehabilitation programme. Predefined study outcomes were recorded by blinded observers at regular intervals for two-years after THA. Radiosteriometric analysis (RSA) was used to assess implant migration. There were no statistical differences between the DSA and PA in postoperative pain scores (p=0.312), opiate analgesia consumption (p=0.067), and time to hospital discharge (p=0.416). At two years follow-up, both groups had comparable Oxford hip scores (p=0.476); Harris hip scores (p=0.293); Hip disability and osteoarthritis outcome scores (p=0.543); University of California at Los Angeles scores (p=0.609); Western Ontario and McMaster Universities Arthritis Index (p=0.833); and European Quality of Life questionnaire with 5 dimensions scores (p=0.418). Radiographic analysis revealed no difference between the two treatment groups for overall accuracy of acetabular cup positioning (p=0.687) and femoral stem alignment (p=0.564). RSA revealed no difference in femoral component migration (p=0.145) between the groups at two years follow-up. There were no differences between patients undergoing the DSA versus PA for THA with respect to postoperative pain scores, functional rehabilitation, patient-reported outcome measurements, accuracy of implant positioning, and implant migration at two years follow-up. Both treatment groups had excellent outcomes that remained comparable at all follow-up intervals

Hemiarthroplasty and proximal femoral fixation are common procedures performed in trauma units, but there is very little information regarding post-operative pain experience. Pain control is a keystone in the successful management of hip fractures. A sound strategy of pain management is easier to implement in patients where pain levels can be predicted, allowing for an effective balanced analgesic regime. Analysis was performed on patients presenting with a hip fracture in two hospitals. Patients with a diagnosis of dementia were excluded. Post-operative pain scores were taken from patient observation charts using a verbal analogue scale. Post-operative opiate consumption was calculated from inpatient drug charts. 357 patients were included, 205 patients underwent a cemented hemiarthroplasty (HG) and 152 had fixation with a dynamic hip screw (DG). No significant difference was found in the length of hospital stay. HG patients recorded a mean morphine requirement of 20.2mg compared with 40.3mg for the DG group. Although the early pain score difference was significant (p=0.009), after 4 days, the scores were equivalent. This may support the notion of non-surgical factors determining the total length of hospital stay. The reason for the elevated pain scores and higher morphine requirement in the DHS group remains unclear. One theory is the fracture site still exists, and it is possible that pre-existing hip arthritis may continue to be symptomatic. It is important to recognise the difference in pain experienced between the groups and analgesia should be tailored towards the individual, allowing for improved peri-operative surgical care and patient experience

Background and objectives: Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts after TKR. The use of peripheral nerve block has certainly reduced the use of opiates by 50%; however adding the sciatic nerve block to the femoral nerve block is controversial. The aim of this study was to compare femoral and femoral plus sciatic nerve blocks in postoperative pain management of patients undergoing TKR. Materials and Methods: Total of 42 patients were studied. Twenty patients with an average of 75yrs (51–86yrs) received femoral nerve block alone. Twenty-two patients with an average age of 69yrs (53–83yrs) received femoral plus sciatic nerve block. 0.5% Chirocaine was used for nerve blocks. There was no significant difference between two groups in terms of pre-operative pain, pre-operative deformity, ROM and patella replaced. The primary outcome measures used were visual analogue scale (VAS) pain scores at 24 hours, 48 hours and 72 hours after the surgery. The amount of opiate consumption and PCA (patient controlled analgesia) used were also recorded. The secondary outcomes were postoperative nausea and vomiting, straight leg raise, neurological deficit, knee flexion, independent mobility and discharge from the hospital. Results: The results showed significant decrease in the amount of pain in the femoral nerve block group than the combined nerve block patients. Patients who had combined nerve block complained of heaviness in the legs and were slow to mobilise. There was no significant difference in consumption of opiates, use of PCA, nausea and vomiting, independent mobility and the time of discharge from the hospital between the two groups. Conclusion: The addition of sciatic nerve block to the femoral nerve block does not provide any additional benefits in TKR

Problems with chondral toxicity caused by prolonged exposure to local anaesthetics have been increasingly recognised. However, day-case hip arthroscopic surgery is frequently carried out using an intraarticular depot of local anaesthetic as post-operative analgesia plus additional opiate or oral analgesia as required. We aimed to evaluate the efficacy of three different post-operative analgesic regimes at hip arthroscopy, in particular examining whether intraarticular local anaesthetics gave any benefit. We investigated 71 consecutive patients undergoing day-case hip arthroscopy and prospectively audited their post-operative analgesic requirements. Each patient was given one of three alternative post-operative analgesic regimes. Group A (n=29) received bupivicaine 0.25% 10ml intraarticular and 20ml peri-portal skin infiltration, group B (n=23) had bupivicaine 0.25% 20ml peri-portal skin infiltration only, and group C (n=19) had no infiltration. Outcome measures were visual analogue scores (VAS) at time-points T1 (immediate post-operatively), T2 (one hour post-operatively), T3 (two hours post-operatively), and T4 (four hours post-operatively). Total opiate consumption was also recorded. There was significantly less post-operative pain in group A, compared with group C at T1 (p=0.03) and T2 (p=0.004), and compared with group B at T3 (p=0.02) and T4 (p=0.03). There were no significant differences in VAS between groups B and C at any time-points. Group A used significantly less opiates post-operatively compared with group B (p=0.008) or C (p< 0.001) but there was no significant difference in opiate use between groups B and C. There are no previous studies relating to hip arthros-copy post-operative analgesic requirements. Intraarticular local anaesthetic significantly reduces post-operative pain, but at what cost to the chondral surface? Local skin infiltration of the arthroscopy portals does not significantly alter pain levels or opiate requirements. Avoidance of intararticular local anaesthetic raises opiate requirements. We require improved alternative analgesic regimes

Aims

In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA).

Aims

Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone.