A Rapid Recovery Program: Early Home and Pain Free

Adolph V. Lombardi Jr., MD; Keith R. Berend, MD; Joanne B. Adams, BFA

Abstract

Enhancement of our perioperative pain management protocols has resulted in accelerated rehabilitation. At our facility, the majority of patients undergoing total and partial knee arthroplasty are treated with a single-shot spinal anesthetic consisting of a combination of bupivacaine and duramorph. The bupivacaine affords the immediate perioperative anesthetic while the duramorph results in sustained analgesia for a period of 12 to 24 hours. We use intra-articular injections delivered directly into the soft tissue of the knee. Our current intra-articular injection is 60 mL of 0.5% ropivacaine with 0.5 mg of epinephrine. In patients with a normal renal function, 30 mg of ketorolac is added. The injection is administered throughout all of the soft tissues in and around the knee. Prophylactic antiemetics are administered in the form of dexamethasone, ondansetron, and a scopolamine patch. The use of this perioperative anesthesia provides effective pain relief with no motor blockade. Patients are able to participate in physiotherapy within several hours of the operative procedure, performing active range of motion and ambulating with assistive devices. Patients with no significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately 2 weeks postoperatively. Additionally, all patients are treated with oxycodone, either preoperatively or within 2 hours of arrival to the floor postoperatively. Patients younger than 70 years are given 20 mg of oxycodone while those older than 70 years are given 10 mg of oxycodone. The oxycodone is continued for the first 24 hours of the hospital stay. Patients are then managed with oxycodone and hydrocodone. Length of stay has decreased and currently averages<2>

A rapid recovery program requires development of a new culture at your practice and hospital. In past eras, and still in some regions of the world, it was thought that a slow convalescence with an extended acute hospital stay of several weeks was the best way for patients to recover and achieve a good outcome after total joint replacement. However, we have learned that by changing our team mindset and streamlining our protocols, patients can recover faster, safer, and with better outcomes.1,2

The process begins preoperatively with an appropriate orthopedic assessment of the patient and determination of the need for surgery. The orthopedic team must motivate the patient, and ensure that the expectations of the patient, family, and surgeon are aligned. Patients deemed candidates for joint replacement are referred to an affiliated hospitalist group to undergo a thorough prescreening physical examination and medical clearance. In a study to determine the benefits of a pre-screening examination, Meding et al3 observed that a remarkable number of new medical diagnoses were established and 2.5% of patients were deemed unacceptable surgical candidates.

Protocols have been developed and implemented to address certain common medical conditions. The prescreening examination includes a nutritional assessment because malnutrition can cause delayed wound healing resulting in a prolonged hospital stay and higher costs.4 In addition, smokers are counseled on preoperative cessation to optimize wound healing and reduce anesthesia risks. Patients are screened for obstructive sleep apnea.5 Those identified are managed with a hospital protocol that includes bringing their continuous positive airway pressure or bi-level positive airway pressure equipment to the hospital, continuous pulse oximetry while inpatient, keeping the head of the bed up, and use of nonsteroidal antinflammatory medications rather than narcotics for pain relief. Average length of stay and minor complications may be increased, but with these steps and vigilance, serious complications can be prevented and obstructive sleep apnea patients can safely undergo joint replacement.

Diabetic patients must be identified and managed carefully when undergoing joint replacement to maintain good glycemic control and avoid complications.6 Patients with cardiac disease require…

Abstract

Enhancement of our perioperative pain management protocols has resulted in accelerated rehabilitation. At our facility, the majority of patients undergoing total and partial knee arthroplasty are treated with a single-shot spinal anesthetic consisting of a combination of bupivacaine and duramorph. The bupivacaine affords the immediate perioperative anesthetic while the duramorph results in sustained analgesia for a period of 12 to 24 hours. We use intra-articular injections delivered directly into the soft tissue of the knee. Our current intra-articular injection is 60 mL of 0.5% ropivacaine with 0.5 mg of epinephrine. In patients with a normal renal function, 30 mg of ketorolac is added. The injection is administered throughout all of the soft tissues in and around the knee. Prophylactic antiemetics are administered in the form of dexamethasone, ondansetron, and a scopolamine patch. The use of this perioperative anesthesia provides effective pain relief with no motor blockade. Patients are able to participate in physiotherapy within several hours of the operative procedure, performing active range of motion and ambulating with assistive devices. Patients with no significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately 2 weeks postoperatively. Additionally, all patients are treated with oxycodone, either preoperatively or within 2 hours of arrival to the floor postoperatively. Patients younger than 70 years are given 20 mg of oxycodone while those older than 70 years are given 10 mg of oxycodone. The oxycodone is continued for the first 24 hours of the hospital stay. Patients are then managed with oxycodone and hydrocodone. Length of stay has decreased and currently averages<2>

A rapid recovery program requires development of a new culture at your practice and hospital. In past eras, and still in some regions of the world, it was thought that a slow convalescence with an extended acute hospital stay of several weeks was the best way for patients to recover and achieve a good outcome after total joint replacement. However, we have learned that by changing our team mindset and streamlining our protocols, patients can recover faster, safer, and with better outcomes.1,2

The process begins preoperatively with an appropriate orthopedic assessment of the patient and determination of the need for surgery. The orthopedic team must motivate the patient, and ensure that the expectations of the patient, family, and surgeon are aligned. Patients deemed candidates for joint replacement are referred to an affiliated hospitalist group to undergo a thorough prescreening physical examination and medical clearance. In a study to determine the benefits of a pre-screening examination, Meding et al3 observed that a remarkable number of new medical diagnoses were established and 2.5% of patients were deemed unacceptable surgical candidates.

Protocols have been developed and implemented to address certain common medical conditions. The prescreening examination includes a nutritional assessment because malnutrition can cause delayed wound healing resulting in a prolonged hospital stay and higher costs.4 In addition, smokers are counseled on preoperative cessation to optimize wound healing and reduce anesthesia risks. Patients are screened for obstructive sleep apnea.5 Those identified are managed with a hospital protocol that includes bringing their continuous positive airway pressure or bi-level positive airway pressure equipment to the hospital, continuous pulse oximetry while inpatient, keeping the head of the bed up, and use of nonsteroidal antinflammatory medications rather than narcotics for pain relief. Average length of stay and minor complications may be increased, but with these steps and vigilance, serious complications can be prevented and obstructive sleep apnea patients can safely undergo joint replacement.

Diabetic patients must be identified and managed carefully when undergoing joint replacement to maintain good glycemic control and avoid complications.6 Patients with cardiac disease require careful oversight; administration of beta-blockers has been shown to decrease perioperative complications.7

Prearthroplasty rehabilitation prepares the patient for perioperative protocols. Patients meet with a physical therapist preoperatively and are provided with extensive educational materials, including an illustrated book, to learn the exercises they will need for functional recovery. Informing the patient and providing preoperative training reduces postoperative pain and anxiety, and ultimately improves outcomes.

Perhaps the single most important outcome from the whole minimally invasive movement has been an enhanced understanding of the multi-modal approach to pain management of patients undergoing arthroplasty.8,9 Enhancement of our perioperative pain management protocols has resulted in accelerated rehabilitation. The anesthesia staff is a key element of the care team, with the anesthesiologist visiting the patient in the preoperative holding area. At our facility, the majority of patients undergoing total joint arthroplasty are treated with a single-shot spinal anesthetic consisting of a combination of bupivacaine and duramorph. The bupivacaine affords the immediate perioperative anesthetic while the duramorph results in sustained analgesia for a period of 12 to 24 hours.

We use intra-articular injections delivered directly into the soft tissue of the hip and knee.10-12 Our current intra-articular injection is 60 mL of 0.5% ropivacaine with 0.5 mg of epinephrine. In patients with a normal renal function, 30 mg of ketorolac is added. The injection is administered throughout all of the soft tissues in and around the joint.

Prophylactic antiemetics are administered in the form of dexamethasone, ondansetron and a scopolamine patch. The use of this perioperative anesthesia provides effective pain relief with no motor blockade. Patients with no significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately 2 weeks postoperatively. Additionally, all patients are treated with oxycodone, either preoperatively or within 2 hours of arrival to the floor postoperatively. Patients younger than 70 years are given 20 mg of oxycodone while those older than 70 years are given 10 mg of oxycodone. The oxycodone is continued for the first 24 hours of the hospital stay. Patients are then managed with oxycodone and hydrocodone.

The operative intervention must be smooth and efficient, but not hurried. Less invasive approaches and techniques have been shown to decrease pain, reduce length of stay, and improve outcomes, especially in the short term.2 The use of custom alignment guides for knee arthroplasty can facilitate preoperative planning, increase operating room efficiency, improve alignment accuracy, and eliminate the need to penetrate the femoral intramedullary canal. Use of wound healing adjuncts such as autologous platelet gels and fibrin sealants decreases blood loss, reduces transfusion needs, and promotes wound healing, which ultimately reduces length of stay and improves outcomes.13 Assess patellofemoral tracking after tourniquet release to reduce the need for lateral retinacular release. Close the knee in flexion to enhance postoperative range of motion (ROM).

An essential component in enhancing recovery is the role of case management. The case manager is a patient advocate who participates in interdisciplinary team rounds and sees the patient every day to reinforce teaching, ensure adherence to surgeon protocols, set daily patient goals and facilitate discharge planning. We have developed aggressive clinical pathways. Patients are able to participate in physiotherapy within several hours of the operative procedure. On the day of surgery, patients perform active ROM and ambulate with assistive devices. Length of hospital stay has decreased and currently averages <2 days.="" postoperative="" physical="" therapy="" has="" an="" important="" role="" in="" increasing="" rom="" and="" improving="" function.="">

The reality of rapid recovery is multifactorial. The expectations of the patient, family, and surgeon must be aligned. Preoperative patient education is essential, and the patient’s medical condition must be optimized. A superior anesthesia team and effective pain management are crucial. The surgeon must perform an efficient operation. A knowledgeable and dedicated physical therapist is vital as an aggressive coach. The ultimate report card for the surgeon is what patients have to say about their joint replacement experience. Monitor patient satisfaction, search for ways to continuously improve, and strive to achieve the highest quality in patient care.

References

  1. Berend KR, Lombardi AV Jr, Mallory TH. Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients. Surg Technol Int. 2004; (13):239-247.
  2. Lombardi AV Jr, Viacava AJ, Berend KR. Rapid recovery protocols and minimally invasive surgery help achieve high knee flexion. Clin Orthop Relat Res. 2006; (452):117-122.
  3. Meding JB, Klay M, Healy A, Ritter MA, Keating EM, Berend ME. The prescreening history and physical in elective total joint arthroplasty. J Arthroplasty. 2007; 22(6 Suppl 2):21-23.
  4. Gherini S, Vaughn BK, Lombardi AV Jr, Mallory TH. Delayed wound healing and nutritional deficiencies after total hip arthroplasty. Clin Orthop Relat Res. 1993; 293:188-195.
  5. Berend KR, Ajluni AF, Núñez-García LA, Lombardi AV, Adams JB. Prevalence of obstructive sleep apnea and management in patient undergoing total joint arthroplasty. J Arthroplasty. 2010. In press.
  6. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009; 91(7):1621-1629.
  7. van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009; 111(4):717-724.
  8. Mallory TH, Lombardi AV Jr, Fada RA, Dodds KL. Anesthesia options: choices and caveats. Orthopedics. 2000; 23(9):919-920.
  9. Mallory TH, Lombardi AV Jr, Fada RA, Dodds KL, Adams JB. Pain management for joint arthroplasty: preemptive analgesia. J Arthroplasty. 2002; 17(4 suppl 1):129-133.
  10. Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, Adams JB. Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty. Clin Orthop Relat Res. 2004; (428):125-130.
  11. Fu P, Wu Y, Wu H, Li X, Qian Q, Zhu Y. Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty–a randomized controlled trial. Knee. 2009; 16(4):280-284.
  12. Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009; 467(6):1418-1423.
  13. Thoms RJ, Marwin SE. The role of fibrin sealants in orthopaedic surgery. J Am Acad Orthop Surg. 2009; 17(12):727-736.

Authors

Drs Lombardi and Berend and Ms Adams are from Joint Implant Surgeons, Inc, The Ohio State University, and Mount Carmel Health System, New Albany, Ohio.

Dr Lombardi receives royalties from, is a paid consultant to, is a paid speaker for, and receives research or institutional support from Biomet, and receives royalties from Innomed. Dr Berend receives royalties from, is a paid consultant to, and receives research or institutional support from Biomet, is a paid consultant to Salient Surgical and Synvasive, and owns stock or stock options in Angiotech. Ms Adams has no relevant financial relationships to disclose.

Presented at Current Concepts in Joint Replacement 2009 Winter Meeting; December 9-12, 2009; Orlando, Florida.

Correspondence should be addressed to: Adolph V. Lombardi Jr, MD, Joint Implant Surgeons, Inc, 7277 Smith’s Mill Rd, Ste 200, New Albany, OH 43054 (LombardiAV@joint-surgeons.com).

doi: 10.3928/01477447-20100722-38

Enhancement of our perioperative pain management protocols has resulted in accelerated rehabilitation. At our facility, the majority of patients undergoing total and partial knee arthroplasty are treated with a single-shot spinal anesthetic consisting of a combination of bupivacaine and duramorph. The bupivacaine affords the immediate perioperative anesthetic while the duramorph results in sustained analgesia for a period of 12 to 24 hours. We use intra-articular injections delivered directly into the soft tissue of the knee. Our current intra-articular injection is 60 mL of 0.5% ropivacaine with 0.5 mg of epinephrine. In patients with a normal renal function, 30 mg of ketorolac is added. The injection is administered throughout all of the soft tissues in and around the knee. Prophylactic antiemetics are administered in the form of dexamethasone, ondansetron, and a scopolamine patch. The use of this perioperative anesthesia provides effective pain relief with no motor blockade. Patients are able to participate in physiotherapy within several hours of the operative procedure, performing active range of motion and ambulating with assistive devices. Patients with no significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately 2 weeks postoperatively. Additionally, all patients are treated with oxycodone, either preoperatively or within 2 hours of arrival to the floor postoperatively. Patients younger than 70 years are given 20 mg of oxycodone while those older than 70 years are given 10 mg of oxycodone. The oxycodone is continued for the first 24 hours of the hospital stay. Patients are then managed with oxycodone and hydrocodone. Length of stay has decreased and currently averages<2>

A rapid recovery program requires development of a new culture at your practice and hospital. In past eras, and still in some regions of the world, it was thought that a slow convalescence with an extended acute hospital stay of several weeks was the best way for patients to recover and achieve a good outcome after total joint replacement. However, we have learned that by changing our team mindset and streamlining our protocols, patients can recover faster, safer, and with better outcomes.1,2

The process begins preoperatively with an appropriate orthopedic assessment of the patient and determination of the need for surgery. The orthopedic team must motivate the patient, and ensure that the expectations of the patient, family, and surgeon are aligned. Patients deemed candidates for joint replacement are referred to an affiliated hospitalist group to undergo a thorough prescreening physical examination and medical clearance. In a study to determine the benefits of a pre-screening examination, Meding et al3 observed that a remarkable number of new medical diagnoses were established and 2.5% of patients were deemed unacceptable surgical candidates.

Protocols have been developed and implemented to address certain common medical conditions. The prescreening examination includes a nutritional assessment because malnutrition can cause delayed wound healing resulting in a prolonged hospital stay and higher costs.4 In addition, smokers are counseled on preoperative cessation to optimize wound healing and reduce anesthesia risks. Patients are screened for obstructive sleep apnea.5 Those identified are managed with a hospital protocol that includes bringing their continuous positive airway pressure or bi-level positive airway pressure equipment to the hospital, continuous pulse oximetry while inpatient, keeping the head of the bed up, and use of nonsteroidal antinflammatory medications rather than narcotics for pain relief. Average length of stay and minor complications may be increased, but with these steps and vigilance, serious complications can be prevented and obstructive sleep apnea patients can safely undergo joint replacement.

Diabetic patients must be identified and managed carefully when undergoing joint replacement to maintain good glycemic control and avoid complications.6 Patients with cardiac disease require…

Abstract

Enhancement of our perioperative pain management protocols has resulted in accelerated rehabilitation. At our facility, the majority of patients undergoing total and partial knee arthroplasty are treated with a single-shot spinal anesthetic consisting of a combination of bupivacaine and duramorph. The bupivacaine affords the immediate perioperative anesthetic while the duramorph results in sustained analgesia for a period of 12 to 24 hours. We use intra-articular injections delivered directly into the soft tissue of the knee. Our current intra-articular injection is 60 mL of 0.5% ropivacaine with 0.5 mg of epinephrine. In patients with a normal renal function, 30 mg of ketorolac is added. The injection is administered throughout all of the soft tissues in and around the knee. Prophylactic antiemetics are administered in the form of dexamethasone, ondansetron, and a scopolamine patch. The use of this perioperative anesthesia provides effective pain relief with no motor blockade. Patients are able to participate in physiotherapy within several hours of the operative procedure, performing active range of motion and ambulating with assistive devices. Patients with no significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately 2 weeks postoperatively. Additionally, all patients are treated with oxycodone, either preoperatively or within 2 hours of arrival to the floor postoperatively. Patients younger than 70 years are given 20 mg of oxycodone while those older than 70 years are given 10 mg of oxycodone. The oxycodone is continued for the first 24 hours of the hospital stay. Patients are then managed with oxycodone and hydrocodone. Length of stay has decreased and currently averages<2>

A rapid recovery program requires development of a new culture at your practice and hospital. In past eras, and still in some regions of the world, it was thought that a slow convalescence with an extended acute hospital stay of several weeks was the best way for patients to recover and achieve a good outcome after total joint replacement. However, we have learned that by changing our team mindset and streamlining our protocols, patients can recover faster, safer, and with better outcomes.1,2

The process begins preoperatively with an appropriate orthopedic assessment of the patient and determination of the need for surgery. The orthopedic team must motivate the patient, and ensure that the expectations of the patient, family, and surgeon are aligned. Patients deemed candidates for joint replacement are referred to an affiliated hospitalist group to undergo a thorough prescreening physical examination and medical clearance. In a study to determine the benefits of a pre-screening examination, Meding et al3 observed that a remarkable number of new medical diagnoses were established and 2.5% of patients were deemed unacceptable surgical candidates.

Protocols have been developed and implemented to address certain common medical conditions. The prescreening examination includes a nutritional assessment because malnutrition can cause delayed wound healing resulting in a prolonged hospital stay and higher costs.4 In addition, smokers are counseled on preoperative cessation to optimize wound healing and reduce anesthesia risks. Patients are screened for obstructive sleep apnea.5 Those identified are managed with a hospital protocol that includes bringing their continuous positive airway pressure or bi-level positive airway pressure equipment to the hospital, continuous pulse oximetry while inpatient, keeping the head of the bed up, and use of nonsteroidal antinflammatory medications rather than narcotics for pain relief. Average length of stay and minor complications may be increased, but with these steps and vigilance, serious complications can be prevented and obstructive sleep apnea patients can safely undergo joint replacement.

Diabetic patients must be identified and managed carefully when undergoing joint replacement to maintain good glycemic control and avoid complications.6 Patients with cardiac disease require careful oversight; administration of beta-blockers has been shown to decrease perioperative complications.7

Prearthroplasty rehabilitation prepares the patient for perioperative protocols. Patients meet with a physical therapist preoperatively and are provided with extensive educational materials, including an illustrated book, to learn the exercises they will need for functional recovery. Informing the patient and providing preoperative training reduces postoperative pain and anxiety, and ultimately improves outcomes.

Perhaps the single most important outcome from the whole minimally invasive movement has been an enhanced understanding of the multi-modal approach to pain management of patients undergoing arthroplasty.8,9 Enhancement of our perioperative pain management protocols has resulted in accelerated rehabilitation. The anesthesia staff is a key element of the care team, with the anesthesiologist visiting the patient in the preoperative holding area. At our facility, the majority of patients undergoing total joint arthroplasty are treated with a single-shot spinal anesthetic consisting of a combination of bupivacaine and duramorph. The bupivacaine affords the immediate perioperative anesthetic while the duramorph results in sustained analgesia for a period of 12 to 24 hours.

We use intra-articular injections delivered directly into the soft tissue of the hip and knee.10-12 Our current intra-articular injection is 60 mL of 0.5% ropivacaine with 0.5 mg of epinephrine. In patients with a normal renal function, 30 mg of ketorolac is added. The injection is administered throughout all of the soft tissues in and around the joint.

Prophylactic antiemetics are administered in the form of dexamethasone, ondansetron and a scopolamine patch. The use of this perioperative anesthesia provides effective pain relief with no motor blockade. Patients with no significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately 2 weeks postoperatively. Additionally, all patients are treated with oxycodone, either preoperatively or within 2 hours of arrival to the floor postoperatively. Patients younger than 70 years are given 20 mg of oxycodone while those older than 70 years are given 10 mg of oxycodone. The oxycodone is continued for the first 24 hours of the hospital stay. Patients are then managed with oxycodone and hydrocodone.

The operative intervention must be smooth and efficient, but not hurried. Less invasive approaches and techniques have been shown to decrease pain, reduce length of stay, and improve outcomes, especially in the short term.2 The use of custom alignment guides for knee arthroplasty can facilitate preoperative planning, increase operating room efficiency, improve alignment accuracy, and eliminate the need to penetrate the femoral intramedullary canal. Use of wound healing adjuncts such as autologous platelet gels and fibrin sealants decreases blood loss, reduces transfusion needs, and promotes wound healing, which ultimately reduces length of stay and improves outcomes.13 Assess patellofemoral tracking after tourniquet release to reduce the need for lateral retinacular release. Close the knee in flexion to enhance postoperative range of motion (ROM).

An essential component in enhancing recovery is the role of case management. The case manager is a patient advocate who participates in interdisciplinary team rounds and sees the patient every day to reinforce teaching, ensure adherence to surgeon protocols, set daily patient goals and facilitate discharge planning. We have developed aggressive clinical pathways. Patients are able to participate in physiotherapy within several hours of the operative procedure. On the day of surgery, patients perform active ROM and ambulate with assistive devices. Length of hospital stay has decreased and currently averages <2 days.="" postoperative="" physical="" therapy="" has="" an="" important="" role="" in="" increasing="" rom="" and="" improving="" function.="">

The reality of rapid recovery is multifactorial. The expectations of the patient, family, and surgeon must be aligned. Preoperative patient education is essential, and the patient’s medical condition must be optimized. A superior anesthesia team and effective pain management are crucial. The surgeon must perform an efficient operation. A knowledgeable and dedicated physical therapist is vital as an aggressive coach. The ultimate report card for the surgeon is what patients have to say about their joint replacement experience. Monitor patient satisfaction, search for ways to continuously improve, and strive to achieve the highest quality in patient care.

References

  1. Berend KR, Lombardi AV Jr, Mallory TH. Rapid recovery protocol for peri-operative care of total hip and total knee arthroplasty patients. Surg Technol Int. 2004; (13):239-247.
  2. Lombardi AV Jr, Viacava AJ, Berend KR. Rapid recovery protocols and minimally invasive surgery help achieve high knee flexion. Clin Orthop Relat Res. 2006; (452):117-122.
  3. Meding JB, Klay M, Healy A, Ritter MA, Keating EM, Berend ME. The prescreening history and physical in elective total joint arthroplasty. J Arthroplasty. 2007; 22(6 Suppl 2):21-23.
  4. Gherini S, Vaughn BK, Lombardi AV Jr, Mallory TH. Delayed wound healing and nutritional deficiencies after total hip arthroplasty. Clin Orthop Relat Res. 1993; 293:188-195.
  5. Berend KR, Ajluni AF, Núñez-García LA, Lombardi AV, Adams JB. Prevalence of obstructive sleep apnea and management in patient undergoing total joint arthroplasty. J Arthroplasty. 2010. In press.
  6. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009; 91(7):1621-1629.
  7. van Klei WA, Bryson GL, Yang H, Forster AJ. Effect of beta-blocker prescription on the incidence of postoperative myocardial infarction after hip and knee arthroplasty. Anesthesiology. 2009; 111(4):717-724.
  8. Mallory TH, Lombardi AV Jr, Fada RA, Dodds KL. Anesthesia options: choices and caveats. Orthopedics. 2000; 23(9):919-920.
  9. Mallory TH, Lombardi AV Jr, Fada RA, Dodds KL, Adams JB. Pain management for joint arthroplasty: preemptive analgesia. J Arthroplasty. 2002; 17(4 suppl 1):129-133.
  10. Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, Adams JB. Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty. Clin Orthop Relat Res. 2004; (428):125-130.
  11. Fu P, Wu Y, Wu H, Li X, Qian Q, Zhu Y. Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty–a randomized controlled trial. Knee. 2009; 16(4):280-284.
  12. Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009; 467(6):1418-1423.
  13. Thoms RJ, Marwin SE. The role of fibrin sealants in orthopaedic surgery. J Am Acad Orthop Surg. 2009; 17(12):727-736.

Authors

Drs Lombardi and Berend and Ms Adams are from Joint Implant Surgeons, Inc, The Ohio State University, and Mount Carmel Health System, New Albany, Ohio.

Dr Lombardi receives royalties from, is a paid consultant to, is a paid speaker for, and receives research or institutional support from Biomet, and receives royalties from Innomed. Dr Berend receives royalties from, is a paid consultant to, and receives research or institutional support from Biomet, is a paid consultant to Salient Surgical and Synvasive, and owns stock or stock options in Angiotech. Ms Adams has no relevant financial relationships to disclose.

Presented at Current Concepts in Joint Replacement 2009 Winter Meeting; December 9-12, 2009; Orlando, Florida.

Correspondence should be addressed to: Adolph V. Lombardi Jr, MD, Joint Implant Surgeons, Inc, 7277 Smith’s Mill Rd, Ste 200, New Albany, OH 43054 (LombardiAV@joint-surgeons.com).

doi: 10.3928/01477447-20100722-38

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