The American journal of orthopedics
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Total knee and hip replacement surgeries are highly invasive, and a significant level of postoperative pain is commonplace in patients undergoing these procedures. It is now known that postoperative pain can affect hospital stay, patient satisfaction, postsurgical rehabilitation, and a range of other clinical and administrative outcomes. The need for a multimodal approach to the control of postoperative pain, using combinations of agents that have synergistic effects, is now widely accepted. ⋯ EXPAREL® (bupivacaine liposome injectable suspension) is an extended-release anesthetic that is approved by the US Food and Drug Administration for single-dose injection into the surgical site to produce postsurgical analgesia. Several phase 2 and phase 3 studies across a range of surgical procedures have demonstrated that the inclusion of EXPAREL® in the multimodal regimen can significantly reduce both pain scores (including cumulative pain scores at 24 hours) and opioid consumption, as well as resulting in delayed time to the first use of opioids and more opioid-free patients at 72 hours. Multimodal regimens that include EXPAREL® may have important benefits in total joint arthroplasty.
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Review Case Reports
Local infiltration of liposome bupivacaine in foot and ankle surgery: case-based reviews.
Foot and ankle surgical procedures, ranging from simple procedures, such as bunionectomy and correction of hammer toe, to more complex surgery, such as ankle fusion and ankle replacement, are extremely painful. Moreover, there is increasing interest in performing these procedures in an outpatient setting. Nerve blocks are extensively used in foot and ankle surgery, and commonly used techniques include sciatic nerve block with saphenous nerve augmentation; ankle block; and local, digital, or field block. ⋯ The first case involves ankle replacement in an active 58-year-old man with a 20-plus-year history of arthritis. The second case involves a young woman undergoing surgery for a talar neck fracture-dislocation with an open injury, dislocated subtalar joint, avascular talus, and considerable deformity. Both patients reported excellent control of postsurgical pain.
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Comparative Study
A biomechanical comparison of superior and anterior positioning of precontoured plates for midshaft clavicle fractures.
With recent studies suggesting improved outcomes in displaced midshaft clavicle fractures treated with open reduction and internal fixation, debate has increased over the preferred plate positioning. Biomechanical studies have yielded conflicting results and have been limited by the almost exclusive use of a simple transverse fracture model. We conducted a study to biomechanically compare superior and anterior plate positioning for clinically relevant midshaft clavicle fracture patterns. ⋯ Results showed that, for all fracture patterns, more construct stiffness was achieved in axial compression and torsion (except for the oblique fracture pattern in clockwise torsion) with a superior plate, whereas more construct stiffness was achieved in cantilever bending with an anterior plate. Oblique fractures were significantly stiffer than bending wedge and complex comminuted fractures. Given the unknown relative importance of loading conditions, absolute recommendations for either superior or anterior plates cannot be made.
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We used decision analysis to assess the cost profile associated with preoperative use of tranexamic acid (TXA) to prevent major bleeding complications associated with hip and knee arthroplasty surgery. We defined major bleeding complications as blood loss sufficient to require transfusion or surgical evacuation of a postoperative hematoma. ⋯ For centers with baseline transfusion rates above 25%, however, TXA becomes increasingly cost-saving as the reduction in transfusion rates seen with use of the drug increases, but a minimum 12% reduction in transfusion rates is needed, even if the expected baseline transfusion rate is 100%. Nevertheless, TXA use is much more likely to be cost-saving, regardless of transfusion rates, if it leads to a reduction in need for revision surgery.
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Review Case Reports
Local infiltration of liposome bupivacaine in orthopedic trauma patients: case-based reviews.
Orthopedic trauma surgery is often associated with considerable postoperative pain, which can result in a cascade of direct and indirect clinical consequences. Patients undergoing orthopedic trauma surgery are at risk for the development of chronic postsurgical pain, which may persist for 2 years or longer. Effective approaches to reducing postoperative pain in orthopedic trauma surgery patients include the use of minimally invasive procedures and multimodal analgesia. ⋯ The first case involves repair of a subtrochanteric nonunion in a 63-year-old woman with a history of bisphosphonate use and prior treatment with a cephalomedullary nail. The second case involves a young woman undergoing outpatient surgery for repair of a fractured clavicle. Both patients experienced good control of postsurgical pain, supporting the clinical utility of EXPAREL® in orthopedic trauma surgery.