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Purpose Orthopedic surgeons can assess bone status intraoperatively and recommend skeletal health evaluation for patients with poor bone quality. Intraoperative physician assessment (IPA) at the time of total knee arthroplasty correlates with preoperative DXA-measured bone mineral density (BMD). This study evaluated IPA during total hip arthroplasty (THA) as a quantitative measure of bone status based on tactile assessment. Methods This retrospective analysis identified 60 patients (64 hips) undergoing primary THA who had IPA recorded in the operative report and a DXA within 2 years before surgery. Intraoperatively, two surgeons assessed bone quality on a 5-point scale (1 = excellent; 5 = poor). IPA score was compared to DXA BMD and T-score, 3D Shaper measurements, WHO classification, FRAX scores, radiographic Dorr classification, and cortical index. Results There was a strong correlation between the IPA score and lowest T-score, WHO classification, and FRAX major and hip fracture scores ( r  =  ± 0.485–0.622, all p  < 0.001). There was a moderate correlation between IPA score and total hip BMD and 3D Shaper measurements, including trabecular volumetric BMD, cortical surface BMD, and cortical thickness ( r  =  ± 0.326–0.386, all p  < 0.01). All patients with below-average IPA scores had osteopenia or osteoporosis by DXA. Conclusion IPA during THA is a simple, valuable tool for quantifying bone status based on tactile feedback. This information can be used to identify patients with poor bone quality that may benefit from skeletal status evaluation and treatment and provide intraoperative guidance for implant selection. Summary Orthopedic surgeons can assess bone health at the time of surgery. Intraoperative physician assessment (IPA) is a bone quality score based on surgeons’ tactile assessment that correlates strongly with the lowest T-score, WHO classification, and FRAX fracture risk. IPA can guide surgical decision-making and future bone health treatment.

Herpes zoster (HZ), commonly called shingles , is a distinctive syndrome caused by reactivation of varicella zoster virus (VZV). This reactivation occurs when immunity to VZV declines because of aging or immunosuppression. Herpes zoster can occur at any age but most commonly affects the elderly population. Postherpetic neuralgia (PHN), defined as pain persisting more than 3 months after the rash has healed, is a debilitating and difficult to manage consequence of HZ. The diagnosis of HZ is usually made clinically on the basis of the characteristic appearance of the rash. Early recognition and treatment can reduce acute symptoms and may also reduce PHN. A live, attenuated vaccine aimed at boosting immunity to VZV and reducing the risk of HZ is now available and is recommended for adults older than 60 years. The vaccine has been shown to reduce significantly the incidence of both HZ and PHN. The vaccine is well tolerated, with minor local injection site reactions being the most common adverse event. This review focuses on the clinical manifestations and treatment of HZ and PHN, as well as the appropriate use of the HZ vaccine.

Background Poly-4-hydroxybutyrate (P4HB) scaffolds are increasingly used to reinforce soft tissue during implant-based reconstruction after mastectomy. P4HB undergoes hydrolytic degradation to a natural metabolite, 4-hydroxybutyrate (4HB). Understanding the direct effects of 4HB on cancer cells is essential for assessing the oncologic safety of P4HB scaffolds used in breast reconstruction surgery. The aim of this study was to evaluate the effects of sodium 4-hydroxybutyrate (Na4HB) on multiple, relevant human breast cancer and epithelial cell types using a panel of well-established in vitro assays aligned with several hallmarks of cancer. Methods First, the clinically relevant tissue concentration of 4HB was determined via a rabbit model to quantify 4HB in the peri-implant tissue of P4HB scaffolds. Second, human breast cell types, including non-malignant HMEC and MCF-10A, and cancerous MCF-7, BT-474 and MDA-MB-231, were exposed to Na4HB at up to 10X the clinically relevant tissue concentration. Cells were then evaluated for cancer related phenotypes: metabolic activity (MTT assay), proliferation (BrdU assay), migration (Scratch and Transwell assays), and colony formation (soft agar assays). Specific inhibitory control compounds for each assay were included to confirm assay performance. Results The average peri-implant concentration of 4HB was found to be 163 µM after a simulated 1-year implantation in a rabbit model. Across the five assays and all three Na4HB concentrations, ranging from below to over 10X the peri-implant level (70, 350, 1750 µM), there was no statistically significant increase in any cancer-related phenotype including metabolic activity, proliferation, migration and colony formation in either malignant or non-malignant cell types compared to controls treated with either the PBS vehicle or sodium acetate as determined by one-way ANOVA followed by Tukey’s multiple comparison test ( p  > 0.05). Conclusions This comprehensive, in vitro evaluation suggests that 4HB does not modify growth or activity of malignant or non-malignant breast cells at concentrations up to 10X the peri-implant level. While these findings suggest that 4HB released from degrading P4HB Scaffolds is unlikely to promote oncogenic behavior in vitro, further co-culture systems, in vivo studies and long-term clinical data can be used to further assess the oncologic safety in breast reconstruction.

Background Fluid extravasation from the shoulder compartment and subsequent absorption into adjacent soft tissue is a well-documented phenomenon in arthroscopic shoulder surgery. We aimed to determine if a qualitative difference in ultrasound imaging of the interscalene brachial plexus exists in relation to the timing of performing an interscalene nerve block (preoperative or postoperative). Methods This single-center, prospective observational study compared pre- and postoperative interscalene brachial plexus ultrasound images of 29 patients undergoing shoulder arthroscopy using a pretest-posttest methodology where individual patients served as their own controls. Three fellowship-trained regional anesthesiologists evaluated image quality and confidence in performing a block for each ultrasound scan using a five-point Likert scale. The association of image quality with age, gender, BMI, duration of surgery, obstructive sleep apnea, and volume of arthroscopic irrigation fluid were analyzed as secondary outcomes. Results Aggregate preoperative mean scores in quality of ultrasound visualization were higher than postoperative scores (preoperative 4.5 vs postoperative 3.8; p  < .001), as was confidence in performing blockade based upon the imaging (preoperative 4.8 vs postoperative 4.2; p  < .001). Larger BMI negatively affected visualization of the brachial plexus in the preoperative period ( p  < 0.05 for both weight categories). Patients with intermediate-high risk or confirmed obstructive sleep apnea had lower aggregate postoperative mean scores compared to the low-risk group for both ultrasound visualization (3.4 vs 4.0; p  < .05) and confidence in block performance (3.8 vs 4.4; p  < .05). Conclusion Due to the potential reduction of ultrasound visualization of the interscalene brachial plexus after shoulder arthroscopy, we advocate for a preoperative interscalene nerve block when feasible. Trial registration ClinicalTrials.gov ( NCT03657173 ; September 4, 2018).

Partial hepatic resection reduces tumor burden in patients with metastatic neuroendocrine tumors, thereby improving quality and length of life. These procedures can be challenging as well as life-threatening. Our aim was to evaluate our patients' perioperative outcomes and propose a definition for an intraoperative carcinoid crisis relevant to this surgery, given its unique surgical considerations. Retrospective study. Mayo Clinic, Rochester, Minnesota. One hundred sixty-nine patients undergoing partial hepatic resection for metastatic neuroendocrine tumors between 1997 and 2015 were identified retrospectively from a surgical database at Mayo Clinic Rochester. None. Intraoperative carcinoid crisis for patients undergoing hepatic resection of neuroendocrine tumors was defined. Patients' medical records were reviewed and data were abstracted describing patient and procedural characteristics and perioperative outcomes. There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). One patient developed clinical findings of an emerging carcinoid crisis, but was successfully treated with doses of octreotide and findings resolved in <10 min. Prophylactically 500 μg octreotide was given subcutaneously in 77% (130/169) of patients preoperatively. There were no documented cases of carcinoid crisis (0.0%, 95% C.I. 0.0% to 2.2%). Adverse events were infrequent. •Intraoperative carcinoid crisis was clearly defined.•Prophylactic octreotide was given to most patients.•No documented cases of carcinoid crisis occurred.

Continuous brachial plexus catheters are often used to decrease pain following elbow surgery. This investigation aimed to assess the rate of early failure of infraclavicular (IC) and axillary (AX) nerve catheters following elbow surgery. Retrospective study. Postoperative recovery unit and inpatient hospital floor. 328 patients who received IC or AX nerve catheters and underwent elbow surgery were identified by retrospective query of our institution's database. Data collected included unplanned catheter dislodgement, catheter replacement rate, postoperative pain scores, and opioid administration on postoperative day 1. Catheter failure was defined as unplanned dislodging within 24 h of placement or requirement for catheter replacement and evaluated using a covariate adjusted model. 119 IC catheters and 209 AX catheters were evaluated. There were 8 (6.7%) failed IC catheters versus 13 (6.2%) failed AX catheters. After adjusting for age, BMI, and gender there was no difference in catheter failure rate between IC and AX nerve catheters (p = 0.449). These results suggest that IC and AX nerve catheters do not differ in the rate of early catheter failure, despite differences in anatomic location and catheter placement techniques. Both techniques provided effective postoperative analgesia with median pain scores < 3/10 for patients following elbow surgery. Reasons other than rate of early catheter failure should dictate which approach is performed. •Infraclavicular (IC) and axillary (AX) nerve catheters both provide effective analgesia following elbow surgery.•Nerve catheter failure rates were similar between IC and AX catheters at 24 hours postoperatively.•Reasons other than early catheter failure should dictate which approach is performed.

The use of regional anesthesia techniques continues to expand in a wide variety of surgical procedures as the benefits and safety are increasingly appreciated. Limb-lengthening procedures are often associated with significant postoperative pain and high opioid requirements which may impact patient's recovery and increase risk of chronic pain and long-term opioid use. The current study retrospectively reviews our experience utilizing a novel peripheral nerve catheter (PNC) protocol for postoperative pain management in patients undergoing elective limb-lengthening procedures. We measure total opioid consumption following 48 hrs in the postoperative period between groups. A total of 70 patients were included from which 41 received general plus regional anesthesia (RA) and 29 were managed with general anesthesia alone (NORA). Postoperative pain needs were calculated as morphine equivalents (ME). There were no differences in the demographic characteristics between the groups. Over the first 48 postoperative hours, opioid use was 0.5 mg/kg ME (IQR 0.3, 0.9) in the RA group versus 1.7 mg/kg ME (IQR 1.1, 3.1) in the NORA group (p<0.001). Subgroup analysis between femoral lengthening and tibial-fibular lengthening procedures demonstrated the same opioid-sparing effect favoring the RA group compared to the NORA group. Hospital length of stay was significantly shorter in the femoral lengthening RA group compared to NORA group (32 hrs [IQR 29, 35] versus 53 hrs [IQR 33, 55], respectively). There was no significant difference in length of stay between the RA group and NORA group after tibial-fibular lengthening procedures. Regional anesthesia via continuous catheter infusions has a clinically significant opioid-sparing effect for postoperative pain management after limb-lengthening procedures and may facilitate earlier hospital discharge.

Background Surgical manipulation of pheochromocytomas and paragangliomas (PPGLs) may induce large hemodynamic oscillations due to catecholamine release. Little is known regarding hemodynamic instability during percutaneous ablation of PPGLs. We examined intraprocedural hemodynamic variability and postoperative complications related to percutaneous ablation of extra-adrenal metastases of PPGL. Methods From institutional PPGL registry we identified patients undergoing ablation of extra-adrenal PPGL metastases from January 1, 2000, through December 31, 2016. We reviewed medical records for clinical characteristics and hospital outcomes. Tumors were categorized as functional or nonfunctional based on preprocedural fractionated catecholamine and metanephrine profiles. Results Twenty-one patients (14 female [67%]) underwent 38 ablations. Twenty-four ablations were performed in patients with functional metastatic lesions, and 14 were in nonfunctional lesions. Intraprocedural use of potent vasodilators for hypertension was higher for patients with functional tumors ( P  = 0.02); use of vasopressors for hypotension was similar for functional and nonfunctional tumors ( P  = 0.74). Mean (±SD) intraprocedural blood pressure range (maximum–minimum blood pressure) during 38 procedures was greater for functional than nonfunctional tumors [systolic: 106 (±48) vs 64 (±30) mm Hg, P  = 0.005; diastolic: 58 (±22) vs 35 (±14) mm Hg, P  = 0.002; mean arterial: 84 (±43) vs 47 (±29) mm Hg, P  = 0.007]. Complications included 5 unplanned intensive care unit admissions (3 for precautionary monitoring, 1 for recalcitrant hypotension, and 1 for hypertensive crisis), 1 case of postoperative bleeding, and 1 death. Conclusions Substantial hemodynamic instability may develop during ablation of functional and nonfunctional PPGL metastases. When anesthesia is provided for ablation of metastatic PPGLs in radiology suites, preparation for hemodynamic management should match standards used for surgical resection.

To study characteristics and outcomes associated with emergency response team (ERT) activation in postsurgical patients discharged to regular wards after anesthesia. We identified all ERT activations that occurred within 48 hours after surgery from June 1, 2008, through December 31, 2009, in patients discharged from the postanesthesia care unit to regular wards. For each ERT case, up to 2 controls matched for age (±10 years), sex, and type of procedure were identified. A chart review was performed to identify factors that may be associated with ERT activation. We identified 181 postoperative ERT calls, 113 (62%) of which occurred within 12 hours of discharge from the postanesthesia care unit, for an incidence of 2 per 1000 anesthetic administrations (0.2%). Multiple logistic regression analysis revealed the following factors to be associated with increased odds for postoperative ERT activation: preoperative central nervous system comorbidity (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.20-5.32; P=.01), preoperative opioid use (OR, 2.00; 95% CI, 1.30-3.10; P=.002), intraoperative use of phenylephrine infusion (OR, 3.05; 95% CI, 1.08-8.66; P=.04), and increased intraoperative fluid administration (per 500-mL increase, OR, 1.06; 95% CI, 1.01-1.12; P=.03). ERT patients had longer hospital stays, higher complication rates, and increased 30-day mortality compared with controls. Preoperative opioid use, history of central neurologic disease, and intraoperative hemodynamic instability are associated with postoperative decompensation requiring ERT intervention. Patients with these clinical characteristics may benefit from discharge to progressive or intensive care units in the early postoperative period.

Spinal anesthesia (SA) has been used relatively sparingly in the pediatric population, as it is typically reserved for patients in whom the perceived risk of general anesthesia is high due to comorbid conditions. Recently, concern has been expressed regarding the potential long-term neurocognitive effects of general anesthesia during the early stages of life. In view of this, our center has developed a program in which SA may be used as the sole agent for applicable surgical procedures. While this approach in children is commonly used for urologic or abdominal surgical procedures, there have been a limited number of reports of its use for orthopedic procedures in this population. We present the use of SA for 6 infants undergoing tendon Achilles lengthening, review the use of SA in orthopedic surgery, describe our protocols and dosing regimens, and discuss the potential adverse effects related to this technique.