IntroductionOpioid-induced hyperalgesia (OIH) and acute opioid tolerance have been demonstrated extensively in patients undergoing adolescent idiopathic scoliosis (AIS) repair. Remifentanil infusion has been strongly linked to both tolerance and OIH in these patients; however, the impact of using an intraoperative fentanyl infusion has not been well studied. This study aims to determine if patients undergoing operative management of AIS have decreased opioid consumption and pain scores when an intraoperative fentanyl infusion is used as compared with a remifentanil infusion.MethodsThis is a retrospective chart review of patients with AIS who underwent posterior spinal fusion. During the period January 2012–June 2013, patients received remifentanil infusion as part of total intravenous anesthesia. From July 2013 to June 2015, remifentanil was replaced by fentanyl as standard protocol. The remifentanil cohort included 37 patients and the fentanyl cohort included 25 patients. The primary outcome was the total opioid consumption (morphine equivalents) in the first 24 hours postsurgery. Secondary outcomes included mean postoperative pain score in the first 24 hours postsurgery, postoperative opioid consumption 24–48 hours after surgery, time to extubation, time to assisted ambulation, length of stay, and incidence of postoperative nausea and vomiting.ResultsCompared with the remifentanil group, the fentanyl group had significantly higher postoperative opioid usage during the first 48 hours and significantly higher postoperative mean pain score during the first 24 hours. There was no difference between the two groups in mean pain score for 24–48 hours, extubation time, time to assisted ambulation, length of stay, or postoperative nausea and vomiting.DiscussionDespite concerns for hyperalgesia and acute tolerance, remifentanil is widely used for intraoperative opioid infusions for surgical correction of AIS. This retrospective study examined a practice change from intraoperative remifentanil to intraoperative fentanyl as a potential approach to avoid OIH. Surprisingly, patients receiving fentanyl intraoperatively showed increased postoperative opioid use and pain scores in the first 24 hours postsurgery compared with the prior cohort receiving remifentanil. Substitution of fentanyl for remifentanil during surgical correction of AIS does not appear to solve the problem of OIH or acute tolerance. Prospective studies are needed to confirm this unexpected result.

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Category: Trauma Introduction/Purpose: The diagnosis of traumatic arthrotomy is typically made through a saline load test (SLT), though there has been a growing base of literature regarding the use of computed tomography (CT) scan in various joints for diagnosis. To date, there has been little data supporting the use of CT to diagnose traumatic arthrotomy of the ankle. Through simulated arthrotomies of the ankle in cadavers, we aim to assess the sensitivity and ability of CT for diagnosing traumatic arthrotomy. SLT were also performed in each specimen to determine the volume of saline needed for diagnosis. Methods: Six fresh-frozen cadavers with twelve ankles were initially included in this study. The presence of intra-articular air prior to arthrotomy was excluded with a baseline CT scan. Ankles underwent arthrotomy at the anterolateral, anteromedial, posteromedial, posterolateral portals with fluoroscopic guidance. A subsequent CT scan was obtained to identify the presence of intra-articular air. Ankles then underwent SLT and volumes resulting in extravasation were recorded. Results: Eleven ankles were included, with one exclusion due to the presence of implants. Arthrotomies were made in three ankles at the anterolateral portal, three at the anteromedial portal, two at the posteromedial portal, and three at the posterolateral portal. Following arthrotomy, intra-articular air was detected in all eleven ankles by CT scan. All eleven ankles were subjected to SLT, with each demonstrating extravasation through the arthrotomy site. The mean volume of saline needed for extravasation was 7.7 mL, with a range of 3 to 22 mL and a standard deviation of 5.4. Conclusion: CT scan was demonstrated to be sensitive and effective in diagnosing traumatic arthrotomy in a cadaveric model.

Obesity, defined as body mass index (BMI) $30, is a serious public health concern associated with an increased incidence of stroke, diabetes, mental illness, and cardiovascular disease resulting in numerous preventable deaths yearly.» From 1999 through 2018, the age-adjusted prevalence of morbid obesity (BMI $40) in US adults aged 20 years and older has risen steadily from 4.7% to 9.2%, with other estimates showing that most of the patients undergoing hip and knee replacement by 2029 will be obese (BMI $30) or morbidly obese (BMI $40).» In patients undergoing total joint arthroplasty (TJA), morbid obesity (BMI $40) is associated with an increased risk of perioperative complications, including prosthetic joint infection and mechanical failure necessitating aseptic revision.Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSREV/A938).

Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse.» A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes. » The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.