* There are multiple available agents and modalities for controlling pain perioperatively during total joint arthroplasty to improve the patient experience, and their unique mechanisms and applications should be considered for use preoperatively, intraoperatively, and postoperatively, keeping in mind that each has differing efficacy and side-effect profiles.* Preoperative pain control or preemptive analgesia using anti-inflammatory drugs and opioid analgesics appears to be effective in reducing postoperative pain, although the recommended timing and type of agents are unclear.* With regard to intraoperative anesthetic choice and pain control, spinal anesthesia appears to have fewer systemic risks than general anesthesia, and periarticular injections of local anesthetic agents, regardless of technique, and with or without the addition of sympathetic modulators, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, have been shown to improve pain scores postoperatively and to overall carry a low risk profile.* When considering postoperative pain control, there are several modalities including cryotherapy, peripheral nerve blockade, and parenteral and enteral medication options including acetaminophen, cyclooxygenase inhibitors, neuromodulators, tramadol, ketamine, and opioid patches, but there is no clearly preferred medication regimen and individual patient risk profiles must be considered when choosing appropriate pain management agents.* Multimodal pain management can decrease opioid usage, improve pain scores, increase patient satisfaction, and enhance early recovery. The ideal preoperative, intraoperative, and postoperative pain medication regimen remains unclear, and an individualized approach to perioperative pain management is recommended. Despite this, good results are demonstrated with the existing variations in pain management protocols in the literature.* Treatment of severe postoperative pain in a multimodal fashion carries the risk for serious side effects, including respiratory depression, mental status changes influencing safe gait mechanics, hypotension, renal and hepatic dysfunction, hematologic variations, gastrointestinal considerations including gastric ulcers, constipation or ileus, nausea or vomiting, infection at injection sites, and peripheral nerve injury with peripheral blockade.

Although total knee arthroplasty is a successful and well-established surgical intervention, there is renewed interest in evaluating its theoretical underpinning and surgical techniques in order to identify areas for potential improvement in patient outcomes.» The practice of using mechanical limb alignment for total knee arthroplasty arose from the design of the modern condylar knee prosthesis, with the goal of equally distributing stresses across the articulating surfaces of the prosthesis. Disclosure: No external funds were received in support of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/ JBJSREV/A441).

Aims Studying the indications for revision total hip arthroplasty (THA) may enable surgeons to change their practice during the initial procedure, thereby reducing the need for revision surgery. The aim of this study was to identify and describe the potentially avoidable indications for revision THA within five years of the initial procedure. Patients and Methods A retrospective review of 117 patients (73 women, 44 men; mean age 61.5 years (27 to 88)) who met the inclusion criteria was conducted. Three adult reconstruction surgeons independently reviewed the radiographs and medical records, and they classified the revision THAs into two categories: potentially avoidable and unavoidable. Baseline demographics, perioperative details, and quality outcomes up to the last follow-up were recorded. Results A total of 60 revision THAs (51.3%) were deemed potentially avoidable and 57 (48.7%) were deemed unavoidable. The following were identified as avoidable factors: suboptimal positioning of the acetabular component (29; 48%), intraoperative fracture or a fracture missed on an intraoperative radiograph (20; 33%), early (less than two weeks) aseptic loosening (seven; 11.7%), and symptomatic leg length discrepancy of > 1 cm (four; 6.7%). Conclusion A surprisingly large proportion of acute revision THAs are potentially avoidable. Surgeons must carefully evaluate the indications for revision THAs in their practice and identify new methods to address these issues. Cite this article: Bone Joint J 2019;101-B(6 Supple B):97–103.

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