The American journal of orthopedics
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The emergence of procedure-specific multimodal pain management regimens that provide effective control of postoperative pain, while markedly reducing the amount of opioid medication required, has been one of the most important advances in hip and knee replacement in recent years. When peripheral nerve blockade first became widely available for inclusion in multimodal regimens, it was viewed as a revolution in the management of postoperative pain. This approach, however, is costly and has some important limitations, including an increased incidence of falls. ⋯ EXPAREL® offers some important clinical and administrative benefits over nerve blocks. Preliminary data from a pilot study comparing the relative effectiveness of EXPAREL® versus sciatic nerve blockade has shown a noticeable reduction in average pain scores at rest with EXPAREL® following both hip and knee arthroplasty, as well as a reduction in the 6- to 12-hour pain score following hip arthroplasty. There was also a significant reduction in opioid use with EXPAREL®, as well as a $411 reduction in the cost of total knee arthroplasty and a $348 reduction in the cost of total hip arthroplasty.
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Comparative Study
Acute achilles tendon ruptures: a comparison of minimally invasive and open approach repairs followed by early rehabilitation.
We retrospectively compared the outcomes of early functional weight-bearing after use of 2 different approaches (minimally invasive, standard) for surgical repair of the Achilles tendon. We reviewed the cases of 63 consecutive patients who underwent repair of an acute closed Achilles tendon rupture and had follow-up of at least 6 months. Of these 63 patients, 33 were treated with a minimally invasive posterolateral approach (minimal group), and 30 were treated with a standard posteromedial approach (standard group). ⋯ At final follow-up, the groups did not differ in their functional outcomes (ability to perform a single heel raise, American Orthopaedic Foot and Ankle Society scores). Used after a minimally invasive posterolateral or standard posteromedial approach, early functional weightbearing is an effective and safe method for treating acute ruptures of the Achilles tendon, and it has a lower rate of soft-tissue complications. A standard posteromedial approach has a higher rate of wound complications, and a minimally invasive posterolateral approach has a higher rate of sural nerve injury.
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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.