Objective: Postoperative pain relief for total knee arthroplasty is an important concern for clinicians who seek to decrease pain, side effects associated with narcotics, increase mobility, and decrease hospital length of stay for total knee arthroplasty (TKA) patients. In today's day in age where patients and clinicians are looking to decrease length of stay and desire to take total knee replacement to the ambulatory surgery setting, appropriate and safe analgesia is paramount. The purpose of this study was to evaluate the analgesic efficacy of implementing a single shot adductor canal block (ACB) protocol in patients undergoing primary TKA by a single surgeon already using a multimodal analgesia protocol at a high volume community hospital. Methods: 75 patients who received a single shot ACB were compared to 75 patients that did not receive an ACB with respect to post-operative NRS pain scores and narcotic consumption. Results: After addition of an ACB there was a 90% reduction in NRS pain scores in the PACU and a 38% reduction at 12 and 24-h post-operatively which were all statistically significant. Total post-operative morphine milligram equivalent (MME) decreased by 51%, after addition of an ACB, which was also statistically significant. Conclusion:The administration of an ACB as an adjunct to a multimodal pain protocol for primary TKA patients is effective at minimizing post-operative pain and narcotic consumption, and plays a critical role in facilitating fast track and same day discharge in our practice.

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Objective: To identify whether residents are at greater risk of radiation exposure from intraoperative fluoroscopy while earlier in their training and during more complex procedures. Methods: We analyzed 852 extracapsular proximal femur fracture fixation cases. We compared fluoroscopy times by various levels of resident training, fracture type, and implant used. Attending-only cases were used as a control group. Results: Fluoroscopy times during subtrochanteric fracture fixation (176.1 ± 11.27 seconds) were longer than intertrochanteric (111.4 ± 2.44 seconds) and basicervical fractures (91.49 ± 5.77 seconds). Long nail (150.2 ± 3.75 seconds) times were longer than short (92.3 ± 3.15 seconds) and intermediate (76.45 ± 3.01 seconds) nails. Significantly, more fluoroscopy was used in junior (115.9 ± 4.24 seconds), senior (123.0 ± 6.08 seconds), junior combo (130.6 ± 7.74 seconds), and senior combo cases (131.8 ± 6.11 seconds) compared with the control (94.91 ± 3.91). Conclusion: Orthopaedic surgery residents and attendings must remain aware of radiation exposure secondary to intraoperative fluoroscopy. Appropriate personal protective equipment should be worn, and more experienced surgeons should take a more active role in the complex cases to decrease exposure risk. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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This paper diabetic ketoacidosis (DKA). Previous literature describes these two disease states presenting together, but most reports describe the etiology as uncontrolled diabetes leading to thyroid storm. After literary review, we present what we believe to be the first case of thyroid storm and DKA occurring in the same person on multiple occasions with an insulin pump. Additionally, we provide evidence that points to the thyroid storm being caused by DKA versus the traditional teaching of DKA precipitating thyroid storm.

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Intraspinal extradural synovial cysts are a rare occurrence at the spinal cord level and thus a rare cause of myelopathy. Synovial cysts usually present in the more mobile lumbar and cervical parts of the spine; however, they may also arise in the thoracic spine. We present a case of a 59-year-old male with a left upper thoracic synovial cyst at T2-3 causing disabling, progressive myelopathy, and an incomplete spinal cord injury syndrome with inability to ambulate. An urgent decompressive laminectomy with bilateral facetectomies, cyst excision, and posterior fusion was performed. Subsequently, the patient recovered full function. Synovial cysts should be considered in the differential diagnosis of progressive thoracic myelopathy. This is only the sixth reported case of a synovial cyst of this kind occurring between the levels of T1 and T7. Urgent surgical decompression is the recommended treatment.