Benjamin E. Stein

Upper-extremity peripheral nerve blocks in the perioperative pain management of orthopaedic patients: AAOS exhibit selection.

BACKGROUND The utilization of peripheral nerve blocks in orthopaedic surgery has paralleled the rise in the number of ambulatory surgical procedures performed. Optimization of pain control in the perioperative orthopaedic patient contributes to improved patient satisfaction, early mobilization, decreased length of hospitalization, and decreased associated hospital and patient costs. Our purpose was to provide a concise, pertinent review of the use of peripheral nerve blocks in various orthopaedic procedures of the lower extremity, with specific focus on procedural anatomy, indications, patient outcome measures, and complications. METHODS We reviewed the literature and reference textbooks on commonly performed lower-extremity peripheral nerve block procedures in orthopaedic surgery, focusing on those most commonly used. RESULTS The use of lower-extremity peripheral nerve blocks is a safe and effective approach to perioperative pain management. Different techniques and timing can have an important impact on patient satisfaction, and each technique has specific indications and complications. For major hip surgery, one of the most commonly used is the lumbar plexus block, which can result in early mobilization, reduced postoperative pain, and decreased opioid-associated adverse events. Associated complications include epidural spread of anesthesia, retroperitoneal hematoma formation, and postoperative falls. For arthroscopic and open knee procedures, the femoral nerve block is frequently used adjunctively. It provides improved early postoperative pain control, early mobilization with therapy, and increased patient satisfaction compared with intra-articular or intravenous opioids alone; it also provides cost savings. However, some studies have shown no significant difference in outcome measures compared with intra-articular opioids alone for arthroscopic anterior cruciate ligament reconstruction. Associated complications include nerve injury, intravascular injection, and postoperative falls. CONCLUSIONS The use of peripheral nerve blocks in lower-extremity surgery is becoming a mainstay of perioperative pain management strategy.

Total Joint Arthroplasty in Patients With Rheumatoid Arthritis: A United States Experience From 1992 Through 2005

To determine whether total joint arthroplasty (TJA) for patients with rheumatoid arthritis (RA) is decreasing, we collected Nationwide Inpatient Sample database information (1992 through 2005) on (1) the number of primary TJAs for all patient diagnoses, (2) the number of primary TJAs for patients with RA, and (3) distribution of age and sex in both groups. To account for population growth, a given years arthroplasty estimate was normalized against its population. The trends over time were analyzed using a multivariable Poisson regression model (significance, P < .05). We found that the number of primary TJA procedures increased in the general and RA populations but that, after adjusting for population growth, age, and sex, the rate was significantly lower in patients with RA.

Changing trends in cervical spine fusions in patients with rheumatoid arthritis.

Study Design. Retrospective data analysis. Objective. To compare the trends in primary cervical spine fusion procedures in patients with rheumatoid arthritis (RA) against those in the general population. Summary of Background Data. RA severely impacts multiple joints in the body and can result in substantial deformity and functional impairment. Cervical spine involvement is common. In the past decade, treatment for RA has changed substantially with the introduction of biologically based, disease-modifying antirheumatic medications. Recent literature has shown decreasing rates of total joint arthroplasty in patients with RA. Methods. Cases of cervical spine fusion in the general population and in patients with RA were identified from the Nationwide Inpatient Sample from 1992 through 2008. US population counts were obtained from the Census Bureau. Data were analyzed with computer software (significance, P < 0.05 for all analyses). Linear regression models were used to describe national rates of cervical spine fusion in patients with and without RA. Results. There was a marked increase in the number of cervical fusion procedures in the studied population. Over time, the incidence of atlantoaxial fusion increased in the general population (P < 0.01) and decreased in patients with RA (P < 0.01). Compared with the general population, patients with RA had a significantly lower rate of increase in the incidence of posterior cervical fusion (P < 0.01) and a significantly higher rate of increase in the incidence of anterior cervical fusion (P < 0.01). Conclusion. In the US, the absolute number of primary cervical fusion procedures from 1992 through 2008 increased in the general population and in patients with RA. However, the patients with RA had a significantly lower incidence of undergoing atlantoaxial and posterior cervical surgical procedures than did the general population. Level of Evidence: 2

Management and prevention of recurrent clostridium difficile infection in patients after total joint arthroplasty: a review.

Clostridium difficile infection (CDI) is the most common infectious cause of nosocomial diarrhea in elderly patients, accounting for 15% to 25% of all cases of antibiotic-induced diarrhea in those patients. Virulent forms of this organism have developed, increasing the associated morbidity, mortality, and complication rates. The average patient undergoing total joint arthroplasty is at particular risk of CDI because of advanced age, the use of prophylactic antibiotic coverage in the perioperative period, multiple comorbid conditions, and length of hospital stay. In addition, patients who have had one CDI are at risk of another; the rate of recurrent CDI (RCDI) is 15% to 30%. To review the available information on RCDI, we conducted an extensive literature search, focusing on its epidemiology and the management strategies for its treatment and prevention. We found the management of RCDI is a controversial topic, with as yet no consensus regarding specific treatment guidelines. Several experienced clinicians have published suggested treatment algorithms, but they are based on anecdotal experience. With regard to the prevention of RCDI, the literature is scarce, and currently, the only effective strategies remain judicious use of perioperative antibiotics and appropriate implementation of infection control procedures. There are several vaccination medications that are currently being studied but are not yet ready for clinical use. We agree with the approach to management of RCDI that has been proposed in several articles, that is, on confirmation of a first recurrence of CDI by a stool toxin assay and clinical symptoms, a 14-day course of metronidazole or vancomycin; for a second recurrence, a tapered-pulsed course of vancomycin; and, for 3 or more recurrences, a repeat course of the tapered-pulsed vancomycin and adjunctive Saccharomyces boulardii or cholestyramine.

Cannulated lag screw fixation of displaced lateral humeral condyle fractures is associated with lower rates of open reduction and infection than pin fixation

Background: Open reduction/internal fixation remains the most common way to surgically stabilize displaced pediatric lateral humeral condyle fractures, but closed reduction and internal fixation is being increasingly used. Our goal was to compare the clinical and functional results of treating displaced pediatric lateral humeral condylar fractures with traditional smooth or threaded pin fixation versus single cannulated screw fixation. Methods: From 1998 through 2012, the lateral humeral condyle fractures of 48 patients were treated with pin fixation (22 patients, until 2006) or cannulated, partially threaded screw fixation (26 patients, from 2006 onward). In each, closed reduction with percutaneous fixation was attempted first, followed by open reduction if anatomic reduction was not achieved. For the pin and screw groups, preoperative maximum radiographic displacement averaged 8.4 mm (range, 3.8 to 18.4 mm) and 6.3 mm (range, 2.2 to 15.5 mm), respectively; follow-up averaged 4.3 months (range, 1.5 to 20 mo) and 10.3 months (range, 2 to 30 mo), respectively. We reviewed preoperative and postoperative images and all follow-up clinical examination findings; serially assessed initial displacement, Baumann and carrying angles, range of motion limitations, and clinical alignment; evaluated functional results via the system of Hardacre and colleagues; and investigated all complications. Results: Open reduction was required in 73% (16/22) and 15% (4/26) of the pin and screw groups, respectively (P<0.001). All fractures were reduced to <1 mm postoperative displacement. Postoperative immobilization averaged 5.9 weeks (range, 4 to 11 wk) and 4.5 weeks (range, 3 to 8 wk) for the pin and screw groups, respectively. The only significant difference in complications was the infection rate: 5 (1 deep) in the pin group and none in the screw group (P<0.05). Conclusions: Closed reduction and percutaneous 4.5-mm lag screw fixation of displaced pediatric lateral humeral condyle fractures is safe and reliable, enabling a higher rate of closed reduction, significantly lower infection rate, and earlier mobilization than traditional pin fixation. Level of Evidence: Level III—Therapeutic.

Postoperative Incentive Spirometry Use

The authors hypothesized that the use of incentive spirometry by orthopedic patients is less than the recommended level and is affected by patient-related factors and type of surgery. To determine its postoperative use, the authors prospectively surveyed all patients in their institutions general orthopedic ward who had undergone elective spine surgery or total knee or hip arthroplasty during a consecutive 3-month period in 2010, excluding patients with postoperative delirium or requiring a monitored bed. All 182 patients (74 men, 108 women; average age, 64.5 years; range, 32-88 years; spine group, n=55; arthroplasty group, n=127), per protocol, received preoperative spirometry education by a licensed respiratory therapist (recommended use, 10 times hourly) and reinforcement education by nurses. Patients were asked twice daily (morning and evening) regarding their spirometry use during the previous 1-hour period by a registered nurse on postoperative days 1 through 3. All data were collected by the same 2 nurses using the same standardized questionnaire. Spirometry use was correlated with surgery type, postoperative day/time, and patients age and sex. Students t test, Spearman test, and one-way analysis of variance were used to compare differences (P<.05). Spirometry use averaged 4.1 times per hour (range, 0-10 times). No statistical correlations were found between spirometry use and age. Sex did not influence spirometry use. The arthroplasty group reported significantly higher use than did the spine group: 4.3 and 3.5 times per hour, respectively. Mean use increased significantly between postoperative days 1, 2, and 3.

Percutaneous Screw Fixation of Lateral Condylar Humeral Fractures

Lateral condylar humeral fractures are the second most common elbow injury in children and commonly occur between the ages of 5 and 10 years. There are several systems for classification of this fracture, including those of Milch (fracture line location) and Jakob et al. (displacement). Although nonoperative management is indicated for nondisplaced or minimally displaced fractures (<2 mm), operative fixation is indicated for greater displacement. Traditionally, open reduction and internal fixation has been the method used to ensure adequate reduction. However, closed reduction and internal fixation techniques for displaced fractures have been receiving increasing attention, with recent studies showing promising results. Several constructs (multiple smooth pins, a single lag screw, and threaded pins) for closed reduction and internal fixation have been described. Smooth-pin fixation has the advantage of a small diameter and easy removal, whereas threaded pins combine a small diameter with compressive properties. Compression of these small, articular fractures is important, and the optimal mode of fixation for maintaining fracture reduction is debated. Fixation with a partially threaded lag screw works by achieving metaphyseal compression, preventing loss of reduction of the distal fragment. In our experience, the compressive abilities of smooth and threaded pins are limited in the soft osteocartilaginous lateral condyle. Partially threaded lag screw fixation is indicated for pediatric patients with a substantially displaced (Jakob type-II or III) lateral condylar fracture. The major steps of the procedure are (1) preoperative planning with anteroposterior, lateral, and oblique radiographs; (2) supine positioning of the patient with the shoulder in abduction; (3) closed reduction with manual pressure; (4) guide-pin insertion through the lateral column of the distal part of the humerus; and (5) exchange of the guide pin with a lag screw. Postoperatively, the elbow is immobilized with a bivalved long-arm fiberglass cast or a posterior splint. The cast or splint is removed after interval healing is demonstrated on radiographs, and the lag screw is removed after complete fracture union is demonstrated. Complications are rare, and patients are expected to have decreased infection and open-reduction rates compared those treated with pin fixation.

Influence of podiatry on orthopedic surgery at a level I trauma center.

Level I trauma centers frequently see trauma at or below the ankle, which requires consultation with the orthopedic surgery department. However, as podiatry programs begin to firmly establish themselves in more Level I trauma centers, their consultations increase, ultimately taking those once seen by orthopedic surgery. A review of the literature demonstrates that this paradigm shift has yet to be discussed. The purpose of this study was to determine how many, if any, lower extremity fracture consultations a newly developed podiatry program would take from the orthopedic surgery department. A retrospective review was performed of emergency department records from January 2007 to December 2011. Seventeen different emergency department diagnoses were used to search the database. Ultimately, each patients emergency department course was researched. Several trends were noted. First, if trauma surgery was involved, only the orthopedic surgery department was consulted for any injuries at or below the ankle. Second, the emergency department tended to consult the podiatry program only between the hours of 8 am and 6 pm. Third, as the podiatry program became more established, their number of consultations increased yearly, and, coincidentally, the orthopedic surgery departments consultations decreased. Finally, high-energy traumas involved only the orthopedic surgery department. Whether the orthopedic surgery department or podiatry program is consulted regarding trauma surgery is likely hospital dependent.

Sawbones comparison of single-rod and double-rod derotation techniques for adolescent idiopathic scoliosis

Background:Although the single-rod derotation technique has been used traditionally to assist in the reduction of thoracolumbar spinal deformity, the double-rod technique may provide improved sagittal reduction. Our goal was to compare these two techniques for thoracolumbar spinal deformity correction. We hypothesized that the single-rod technique would lead to comparable or better correction in the coronal and sagittal planes. Methods:We used eight Sawbones® (Pacific Research Laboratories, Inc., Vashon, WA) spine models with King type II deformities and obtained 36-inch anteroposterior and lateral conventional radiographs. The models were assigned, four each, to two technique groups. In each group, two models were instrumented with pedicle screw fixation from the T4 to L1 levels and two were instrumented from the T3 to L1 levels. Monoaxial screw heads were used at the apex level and at the two levels above and below the apex. Polyaxial screw heads were used in the remaining levels. Rods were contoured appropriately to each model, and the reductions were performed as described in the respective literature. Repeat radiographs were obtained, and measurements were recorded and compared. Results:The double-rod technique provided a 58% correction in the thoracic curve, a 55% correction in the lumbar curve, and a 1.1-cm increase in sagittal imbalance. The single-rod technique provided an 84% correction in the thoracic curve, a 75% correction in the lumbar curve, and a 1.5-cm reduction in sagittal imbalance. Conclusions:The single-rod technique achieved better coronal and sagittal correction. The double-rod technique had simultaneous rotation of both rods, leading to an incongruent final position and decreased correction.

Prevalence of Allograft Contamination During Intraoperative Processing for Spinal Deformity Correction Surgery

STUDY DESIGN Prospective study. OBJECTIVES To prospectively evaluate bone allografts during spinal fusion surgery for 1) the rate of contamination as a result of perioperative preparation, and 2) the types of bacterial organisms that may be transmitted through the contaminated bone allograft. SUMMARY OF BACKGROUND DATA Bone allografts are routinely used to enhance spinal arthrodesis procedures. Ready availability and lack of donor site morbidity make them valuable alternatives to iliac crest bone grafts. Reports of disease transmission of such organisms as hepatitis C, the human immunodeficiency virus, and a variety of bacterial pathogens through allograft bone implants raise concerns for patient and practitioner safety. METHODS Our study population consisted of 50 consecutive (20 male and 30 female) patients (mean age at surgery, 15 years; range, 3-51 years) undergoing spinal deformity correction from May 2010 through October 2010, by 1 surgeon at 1 institution. The mean operative time was 297 minutes (range, 81-444 minutes), and the most commonly fused spinal levels were T5 to L4. During the procedure, the researchers prospectively obtained intraoperative microbial culture swabs from a container with freeze-dried allograft and from an empty identical control container. Aerobic and anaerobic bacterial culture growth was assessed for 7 days postoperatively. Each patient was observed for 6 weeks after surgery to ascertain any evidence of surgical-site infection. RESULTS Microbial cultures showed bacterial growth in 4 cases: 1 allograft specimen (day 4, very light Staphylococcus aureus) and 3 control specimens (day 3, very light Enterococcus; day 4, very light S aureus; and day 6, Propionibacterium acnes). No patient showed signs of infection in the perioperative or 6-week postoperative period. CONCLUSIONS Intraoperative allograft preparation is not a major source of bone allograft contamination during spinal surgery.