Background: This study compares postoperative pain scores and functional outcomes between liposomal bupivacaine peri-articular injection (LB-PAI) vs a single-shot adductor canal block (ACB) using bupivacaine HCl in patients undergoing primary total knee arthroplasty (TKA). Methods: This is a randomized controlled trial of 56 patients who were treated with TKA for arthritis. Patients were randomized to receive an intraoperative LB-PAI (n ¼ 27) or preoperative ACB using bupivacaine HCl (n ¼ 29). Both groups were otherwise given our institutional standard multimodal pain protocol. Data on Visual Analog Scale (VAS) pain scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, knee range of motion, postoperative ambulation distance, hospital length of stay, and opioid use were collected. The total cost of each intervention was compared at the conclusion of the study. Results: Age, gender, or body mass index was similar between groups. Compared to the ACB group, the LB-PAI group trended to lower average VAS pain scores on postoperative days 0, 1, and 2 (average difference [95% confidence interval] ¼ À0.5 [À0.7, 1.7], À1.0 [À0.1, 2.0], À0.2 [À0.8, 1.3]), and identical average VAS pain scores on postoperative days 4 and 7. These differences and all postoperative outcome measures were not statistically significant at any time point. A single 266-milligram vial of liposomal bupivacaine costs $351, and a single-shot ACB costs $893 at our institution. Conclusions: This randomized controlled trial shows similar postoperative pain control, functional outcomes, and opioid use between LB-PAI and a single-shot ACB in patients undergoing primary TKA.

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In this study, we aimed to compare the effectiveness of one dose of tranexamic acid (TXA) at the time of hospital admission versus two doses of TXA (one at the time of hospital admission and another dose intraoperatively) in reducing perioperative total blood loss in patients with extracapsular hip fractures. MethodsThis retrospective cohort study included 80 patients from a single institution who underwent surgical fixation for extracapsular hip fractures. Forty patients received a single dose of 1 gram of TXA at the time of hospital admission (per standardized protocol of an ongoing research study at the time), and 40 patients received the same dose of TXA on hospital admission as well as a second dose of 1 gram of TXA intraoperatively at the time of incision (per standard practice change following the completion of the research study). The primary study outcome of interest was total blood loss, which was calculated by estimating blood volume via Nadler's formula followed by calculating the total blood loss with the hemoglobin dilution method. Secondary outcomes included blood transfusion rates, hospital length of stay (LOS), and 30-day mortality. ResultsPatient gender, age, the American Society of Anesthesiologists (ASA) score, procedure length, fracture type, hardware type, and hemoglobin on hospital arrival were similar across the study groups (all p>0.05), though the twice-dosed group had a higher average BMI (26.4 kg/m 2 vs. 24 kg/m 2 , p=0.04). When adjusting for BMI, the twice-dosed group was estimated to have a slightly larger but non-significant difference in total blood loss (115-ml difference, 95% CI: 158.2-389.3, p=0.40) compared to the single-dose TXA group. More patients in the twice-dosed group required blood transfusion compared to the single-dose TXA group, though this was not statistically significant (30.0% vs. 17.5%, adjusted OR=1.64, 95% CI: 0.55-5.12, p=0.38). The distribution of hospital LOS and 30-day mortality rates were similar across the groups (p=0.13 and p>0.99). ConclusionIn the setting of surgically treated extracapsular hip fractures, patients who received one dose of TXA at the time of hospital admission and a second intraoperative dose of TXA did not demonstrate significant differences in total blood loss or a need for blood transfusion compared to patients who only received a single dose of TXA at the time of hospital admission.

Introduction: Prosthetic joint infection (PJI) is a serious complication after total joint replacement (TJR). Adequate wound oxygenation is critical for wound healing and infection prevention. As carbon dioxide (CO 2 ) is exchanged for oxygen (O 2 ) in the lungs, serum bicarbonate (HCO 3 - ) may be used as a marker for predicting relative serum O 2 levels, and therefore, healing potential. No currently published literature explores the relationship between serum bicarbonate levels and PJI in TJR patients. Methods: We performed this retrospective review of lower extremity TJR patients to determine whether the risk of PJI and wound complications within one year was correlated with hypercarbia, which was defined as a preoperative serum bicarbonate level >30 mEq/L. Results: Out of 1,690 TJR procedures, 1.6% (N=27) had a PJI or superficial wound infection within one year postoperatively. The average preoperative serum bicarbonate was 26.9 (SD 2.6) among patients without PJI and 27.2 (SD 2.1) among patients with PJI (p=0.46). Hypercarbia was present in 9.2% of non-PJI patients and in 7.4% of PJI patients. The relative risk of PJI and wound complications did not differ for patients with vs without hypercarbia (RR = 0.79, 95% CI = 0.19-3.31, p=0.75). Conclusion: The results of this study provide preliminary evidence that preoperative hypercarbia may not be correlated with an increase in the risk of PJI or wound complications. However, due to the rarity of both PJI and hypercarbia, a larger patient population is needed to ensure adequate power to detect clinically meaningful effect sizes.