Safety of Cryoneurolysis as a Preoperative Treatment for Total Knee Arthroplasty (TKA).

Cryoneurolysis is a minimally invasive procedure that utilizes extreme cold temperature to achieve thermal neurolysis of peripheral sensory nerves. This study aimed to evaluate the safety of cryoneurolysis as a preoperative treatment for total knee arthroplasty (TKA) and assess the incidence of major and minor wound complications associated with the procedure. A retrospective chart review was conducted on 357 patients who underwent cryoanalgesia within two weeks of their scheduled TKA. The study found that cryoneurolysis as a preoperative treatment for TKA did not demonstrate an increased incidence of major complications, including acute periprosthetic joint infections, skin necrosis, or permanent treatment site nerve damage/neuroma compared to published rates of infection. Complications were minimal, with only three cases of infection and five cases of superficial cellulitis observed; however, none were directly attributable to the cryoneurolysis procedure. These findings are encouraging and suggest that cryoneurolysis is a relatively safe adjunct procedure with a similar risk of major or minor complications when used as a preoperative treatment for TKA.

New Evaluation and Management Code Level Selection Trends in Hip and Knee Osteoarthritis Patients.

BACKGROUND: On January 1, 2021, the American Medical Association implemented changes regarding the outpatient Evaluation and Management (E/M) criteria dictating Current Procedural Terminology code level selection to help diminish administrative burden and emphasize medical decision-making as the primary determinant in E/M level of service (EML). The goal of this study was to describe EML coding trends in outpatient visits for hip and knee osteoarthritis after the 2021 Centers for Medicare and Medicaid Services changes to the E/M system. METHODS: All outpatient visits for primary hip and knee osteoarthritis within the divisions of Joint Replacement, Operative Sports Medicine, and Nonoperative Sports Medicine at a single orthopaedic practice were retrospectively analyzed during 2 separate 10-month timeframes in 2019 and 2021. The primary endpoint was the visit EML (1 through 5) based on Current Procedural Terminology E/M codes. RESULTS: In 2019, 7.8% of all visits were billed as level 2, 85.8% of all visits were billed as level 3, and 6.3% of all visits were billed as level 4. In 2021, 2.8% of visits were billed as level 2, 54% of visits were billed as level 3, and 41.3% of visits were billed as level 4. Level 1 and Level 5 visits did not exceed 2% in either year. Across all 3 divisions, level 2 and 3 visits decreased significantly (P < .05), while level 4 visits increased significantly (P < .05). CONCLUSION: Since the E/M coding criteria overhaul in 2021, there has been a significant trend towards higher level of service code selection across multiple divisions in our orthopaedic practice.

A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study.

BACKGROUND: Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively. METHODS: Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain. RESULTS: From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing. CONCLUSIONS: The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.

Safety and Duration of Low-Dose Adjuvant Dexamethasone in Regional Anesthesia for Upper Extremity Surgery: A Prospective, Randomized, Controlled Blinded Study.

BACKGROUND: Orthopedic procedures concerning the upper extremity commonly use a brachial plexus nerve block to achieve postoperative analgesia. The addition of dexamethasone to peripheral nerve blocks has been shown to significantly prolong its effect. We hypothesize that 1 mg doses of dexamethasone will prolong brachial plexus nerve block with similar efficacy to 4 mg and better than ropivacaine alone. METHODS: Seventy-nine patients who received a brachial plexus nerve block prior to undergoing upper extremity surgery were randomized to 1 of 4 treatment groups: group 1 received only 30 mL of 0.5% ropivacaine without dexamethasone (control); groups 2, 3, and 4 received 4, 2, and 1 mg of dexamethasone, respectively, added to 30 mL of 0.5% ropivacaine. RESULTS: Comparison of block duration, specifically "first signs of the block wearing off" to the 0-mg group, referencing the 1-, 2-, and 4-mg groups (P = .02, .04, and .01, respectively) that received steroid adjuvant therapy demonstrated a significant increase in time until the block began to wear off. All study groups receiving steroids also demonstrated a significant increase in duration of the block prior to its effects being completely gone when compared with the control group (P < .01 for all groups). CONCLUSIONS: Our findings demonstrate that adjuvant dexamethasone can prolong brachial plexus nerve blocks effectively at low doses compared with high doses, in addition to prolonging analgesia compared with local anesthetic alone.

Perioperative Pain Management in Ambulatory and Inpatient Shoulder Surgery.

¼: Acetaminophen is an effective addition to a multimodal pain regimen; however, evidence to support intravenous versus oral administration requires further evaluation. ¼: While nonsteroidal anti-inflammatory drugs are a valuable addition to a multimodal pain strategy, concerns regarding their effect on healing after certain procedures (i.e., rotator cuff repair) in select patients may preclude their use. ¼: The use of perioperative gabapentinoids have varied results for pain control, and additional research is warranted to support their use after certain shoulder procedures. ¼: Opioid-prescribing should be limited and reserved for severe postoperative pain. When prescribed, opioids should be taken at the lowest possible dose and for the shortest period. ¼: Centrally acting analgesics such as tramadol have been shown to be as effective as opioids and have a lower risk of complications. ¼: Nerve blocks are an excellent addition to multimodal pain management strategies. Longer-lasting formulations of perioperative single-shot injections and indwelling catheters may reduce rebound pain.

Low Incidence of Asymptomatic Positive Patients Detected During Preoperative Testing for Total Joint Arthroplasty During the COVID-19 Pandemic.

INTRODUCTION: Although the pause in elective surgery was necessary to preserve healthcare resources at the height of the novel coronavirus disease 2019 (COVID-19) pandemic, recent data have highlighted the worsening pain, decline in physical activity, and increase in anxiety among cancelled total hip and knee arthroplasty patients. The purpose of this study was to evaluate the effectiveness of our staged reopening protocol and the incidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among elective arthroplasty patients. METHODS: We identified all elective hip and knee arthroplasty patients who underwent our universal COVID-19 testing protocol during our phased reopening between May 1, 2020, and July 21, 2020, at our institution. We recorded the SARS-CoV-2 test results of each patient along with their demographics, medical comorbidities, and symptoms at the time of testing. We followed each of these positive patients through their rescheduled cases and recorded any complications or potential SARS-CoV-2 healthcare exposures. RESULTS: Of the 2,329 patients, we identified five patients (0.21%) with a reverse transcription-polymerase chain reaction--confirmed SARS-CoV-2 positive test, none with symptoms. All patients were successfully rescheduled and underwent their elective arthroplasty procedure within 6 weeks of their original surgery date. None of these patients experienced a perioperative complication at the time of their rescheduled arthroplasty procedure. No orthopaedic surgeon or staff member caring for these patients reported a positive SARS-CoV-2 test. CONCLUSION: Our phased reopening protocol with universal preoperative virus testing was safe and identified a low incidence of SARS-CoV-2 among asymptomatic, elective arthroplasty patients at our institution. With uncertainty regarding the trajectory of the COVID-19 pandemic, we hope that this research can guide future policy decisions regarding elective surgery.