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Selection of appropriate candidates for simultaneous bilateral total knee arthroplasty (si-BTKA) is crucial for minimizing postoperative complications. The aim of this study was to develop a scoring system for identifying patients who may be appropriate for si-BTKA. Patients who underwent si-BTKA were identified in the National Surgical Quality Improvement Program database. Patients who experienced a major 30-day complication were identified as high-risk patients for si-BTKA who potentially would have benefitted from staged bilateral total knee arthroplasty. Major complications included deep wound infection, pneumonia, renal insufficiency or failure, cerebrovascular accident, cardiac arrest, myocardial infarction, pulmonary embolism, sepsis, or death. The predictive model was trained using randomly split 70% of the dataset and validated on the remaining 30%. The scoring system was compared against the American Society of Anesthesiologists (ASA) score, the Charlson Comorbidity Index (CCI), and legacy risk-stratification measures, using area under the curve (AUC) statistic. Total 4,630 patients undergoing si-BTKA were included in our cohort. In our model, patients are assigned points based on the following risk factors: +1 for age ≥ 75, +2 for age ≥ 82, +1 for body mass index (BMI) ≥ 34, +2 for BMI ≥ 42, +1 for hypertension requiring medication, +1 for pulmonary disease (chronic obstructive pulmonary disease or dyspnea), and +3 for end-stage renal disease. The scoring system exhibited an AUC of 0.816, which was significantly higher than the AUC of ASA (0.545; p

Background Total Elbow Arthroplasty (TEA) has demonstrated promising functional outcomes for the treatment of complex distal humerus fractures. In many other joints, arthroplasty for trauma is associated with increased risks for acute postoperative complications. The purpose of this investigation is to identify the in-hospital and 30-day postoperative complications for TEA performed because of distal humerus fracture vs. arthritis, and to determine whether acute fracture is associated with differences in complications after TEA. Methods The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent TEA from 2006 to 2018. Patients who were diagnosed with distal humerus fractures were identified and compared with patients without acute fracture. Patients without fracture were further divided into those undergoing TEA for Rheumatoid Arthritis (RA) vs. osteoarthritis (OA). Demographic data, length of hospital stay, readmission rate, reoperation rate, and postoperative complications within 30 days were analyzed by univariate analysis. Multivariable logistic regression was used to isolate the effect of acute fracture on postoperative complications and readmission. Results Six hundred fourty-six patients underwent TEA, and 149 (23.1%) had undergone TEA for distal humerus fracture. Patients undergoing TEA for fracture had an overall adverse event rate of 13.42% compared to a complication rate of 12.47% in patients undergoing primary elective TEA (P = .76). On univariate analysis, patients who underwent TEA for fracture were not significantly more likely to require reoperation within 30 days (1.34% vs. 4.63% for RA and 4.11% for OA, P = .24) or require readmission within 30 days (5.37% vs. 4.63% for RA and 4.88% for OA, P = .52). Multivariable logistic analysis found that TEA for fracture was not independently associated with readmission, reoperation, major complications, or minor complications. Increasing age is associated with increased risk of minor complications. Female gender is associated with decreased risk of major complication, and higher ASA classification was associated with increased odds of readmission. Conclusions Acute fracture is not an independent risk factors for major complications, reoperation, or readmissions in patients undergoing TEA. Level of Evidence Level III; Retrospective Case-Control Study.

Backgroud Many U.S. health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. A major determinant of payment and wRVU assignments is operative time. We sought to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common shoulder/elbow procedures. Methods We collected data on wRVUs, payments, and operative times from CMS for 29 types of isolated arthroscopic and open shoulder/elbow procedures. Using regression analysis, we compared relationships between these variables, in addition to median operative times reported by NSQIP (2013-2016). We then determined the relative valuation of each procedure based on operative time. Results Seventy-nine percent of CMS operative time were longer than NSQIP time (R2 = 0.58), including, but not limited to, shoulder arthroplasty and arthroscopic shoulder surgery. The correlation between payments and operative times was stronger between CMS data (R2 = 0.61) than NSQIP data (R2 = 0.43). Similarly, the correlation between wRVUs and operative times was stronger when using CMS data (R2 = 0.87) than NSQIP data (R2 = 0.69). Nearly all arthroscopic shoulder procedures (aside from synovectomy, debridement, and decompression) were highly valued according to both datasets. Per NSQIP, compensation for revision total shoulder arthroplasty ($10.14/min; 0.26 wRVU/min) was higher than that for primary cases ($9.85, 0.23 wRVU/min) and nearly twice the CMS rate for revision cases ($5.84/min; 0.13 wRVU/min). Conclusions CMS may overestimate operative times compared to actual operative times as recorded by NSQIP. Shorter operative times may render certain procedures more highly valued than others. Case examples show that this can potentially affect patient care and incentivize higher compensating procedures per operative time when less-involved, shorter operations have similar patient-reported outcomes.

The purpose of this study is to determine differences in the rates of 90-day postoperative complications and 2- and 5-year surgical outcomes between patients with and without hereditary hemochromatosis (HH) after total joint arthroplasty (TJA).Patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) from 2010 to 2018 were identified in a national database (PearlDiver Technologies) using Current Procedural Terminology and International Classification of Diseases-9/10 codes. Patients with a history of HH were identified within the THA and TKA cohorts and matched with non-HH patients based on age, sex, Charlson Comorbidity Index, smoking status, and obesity (body mass index30). Ninety-day medical complications assessed included renal failure, arrhythmia, bleeding complications, blood transfusion, pneumonia, stroke, deep vein thrombosis, liver failure, heart failure, pulmonary embolism, sepsis, surgical site infection, wound dehiscence, readmission rate, and death. Two- and 5-year surgical complications assessed included all-cause revision, prosthetic joint infection, implant loosening, joint stiffness, and manipulation under anesthesia. All complications were analyzed using bivariate analysis and logistic regression, with significance set at P0.05.Compared with non-HH patients, patients with HH had higher rates of stiffness at 2 and 5 years after THA (all, P0.001), as well as higher rates of aseptic loosening at 5 years after TKA (P = 0.036). However, patients with HH undergoing THA and TKA had no notable difference in 90-day postoperative complications when compared with non-HH patients.Compared with non-HH patients, patients with HH undergoing TJA were shown to have worse 2- and 5-year surgical outcomes, without any increased risk of 90-day medical complications. These findings may be useful for surgical decision making for patients with HH undergoing TJA.This study addresses a paucity in the current literature concerning the complication profile in HH patients with destructive joint arthropathy undergoing joint arthroplasty surgery.

Upper extremity surgeons perform diverse operations, including hand surgery, microsurgery, and shoulder/elbow arthroscopy and arthroplasty. Declining orthopedic reimbursement rates may encourage surgeons to adjust their case mix, favoring a shift toward procedures with higher compensation. To determine whether upper extremity surgeons and hand-fellowship trainees may be financially incentivized to perform more shoulder/elbow procedures than hand procedures in a hospital-based setting, relative value unit (RVU) compensation rates were compared for these 2 fields. Using Centers for Medicare & Medicaid Services–assigned work RVUs (wRVU) and National Surgical Quality Improvement Program operative time data, wRVU compensation rates per minute of operative time were determined for common shoulder/elbow surgeries. Overall nonweighted and weighted wRVU/min averages were calculated for hospital-based shoulder/elbow and hand surgery. A total of 27 shoulder/elbow procedures and 53 hand surgery procedures were analyzed. Nonweighted comparison showed shoulder/elbow surgery had a higher wRVU/min (0.19±0.03 vs 0.14±0.05, P P Orthopedics . 2021;44(3):e373–e377.]

Background Prescription opioid misuse has become an epidemic in the United States and is a leading cause of death in Americans. Postoperative opioid prescriptions are a significant contributor to the opioid epidemic, with orthopedic surgeons being the third highest prescribers of opioid prescriptions among physicians across all specialties. Our aim was to retrospectively evaluate overall opioid consumption patterns following surgical treatment for shoulder pathology and recommend evidence-based guidelines for standardized postoperative opioid prescriptions. Methods We conducted a retrospective chart review of patients who underwent shoulder arthroscopy or arthroplasty from a single shoulder/elbow fellowship-trained surgeon (principal investigator). Patient and surgery characteristics were summarized for the entire sample and further stratified by surgery type. Total opioid consumption at the time of the first postoperative visit and refill patterns were compared between each surgery group. Opioid consumption was analyzed in morphine milligram equivalents (MMEs) and is reported in the equivalent number of 5-mg oxycodone tablets. Results A total of 119 patients were included in our analysis. The average age was 58 ± 13 years, and 59% of patients were male. Rotator cuff repair was the most frequent surgery (n = 52), followed by arthroplasty (n = 35) and arthroscopy (n = 28). On average, the patients in the study used 82.5 ± 233 MME units, equivalent to 11 ± 31.067 tablets of 5-mg oxycodone. Sixteen percent of patients did not use any opioids. There was no significant difference in opioid consumption or refills across surgery type. In the bivariate analysis for the entire sample, age was the only predictor that was statistically significantly associated with the amount of opioid consumption. In the multivariable model for patient demographics, significant predictors of opioid consumption were age, gender, and pain scores. In the multivariate analysis by surgery type, significant predictors of higher opioid consumption were age, gender, pain score, and surgery performed on the dominant side. Conclusion On the basis of the consumption patterns observed in our patient cohort, we recommend prescribing 112.5 MME (15 tablets of 5-mg oxycodone) for arthroscopic shoulder procedures, and 75 MME (10 tablets of 5-mg oxycodone) for shoulder arthroplasties.

BACKGROUND: Many US health care institutions have adopted compensation models based on work relative value units (wRVUs) to standardize payments and incentivize providers. Among other factors, a major determinant of payment and wRVU assignments is operative time. Our objective was to determine whether differences in estimated operative times between the Centers for Medicare & Medicaid Services (CMS) and the National Surgical Quality Improvement Program (NSQIP) contribute to payment and wRVU misvaluation for the most common hospital-based hand and upper extremity procedures. METHODS: Data on wRVUs, surgeon payment, and estimated operative times were collected from CMS for 53 procedures. We used regression models to compare relationships between these variables, in addition to actual median operative times as reported in the NSQIP database, from 2011 to 2016. We then determined the relative valuation of each procedure based on operative time. RESULTS: There was a wide discrepancy between CMS and NSQIP operative times (R(2)=0.49), with 60% of CMS times being longer than NSQIP times. Payment correlated more strongly with CMS operative times (R(2)=0.55) than with NSQIP operative times (R(2)=0.24). Similarly, wRVUs more strongly correlated with CMS operative times (R(2)=0.84) than with NSQIP operative times (R2=0.51). In general, for trauma-related procedures, any distal radius open reduction internal fixation (ORIF) had the highest valuation while any ORIF proximal to the distal radius had lower valuation in analysis of both databases. While 61% of trauma procedures were highly valued, 70% of elective procedures had a low valuation, including nearly all elective tendon procedures. Notable compensation differences were found between trapeziectomy versus ligament reconstruction and tendon interposition, epicondyle debridement with tendon repair versus denervation, proximal row carpectomy versus four corner fusion, and distal radius open versus percutaneous fixation. CONCLUSIONS: CMS may misvalue payment and wRVU rates of hospital-based hand procedures due to inaccurate operative time estimates. By identifying which procedures are misvalued in terms of payment and wRVU per operative time, providers and payors may be able to address these imbalances and maximize appropriate care delivery incentives. Level of Evidence: III

BACKGROUND: There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to the perception that this exposure will improve their professional “marketability” in a subspecialty they perceive as having higher compensation. METHODS: Using Medicare data, we investigated the most common surgeries from these fields and determined which have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement (payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weighted and weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than that of hand surgery. RESULTS: Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest payment and wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius open reduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignments with correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgery has a higher mean payment/min ($10.46±3.22 vs. $7.52±2.89), charge/min ($51.02±17.11 vs. $41.96±11.32), and reimbursement (21±4.7% vs. 18±5.1%) compared with shoulder/elbow surgery (all, P

Objectives: The purpose of this study was to biomechanically compare six techniques for biceps tenodesis to evaluate the potential difference of anchor size, type and configuration (single- versus double-loaded). The six techniques were interference screws (IS), endobutton (EB), double-loaded 2.9mm PEEK anchor (DL-2.9), double-loaded 1.9mm all-suture anchor (DL-1.9), single-loaded 1.7mm all-suture anchor (SL-1.7), and soft tissue tenodesis (ST) (Smith and Nephew, Memphis, TN, USA). Methods: 42 fresh-frozen cadaver shoulders (mean age, 72 years [range 54 to 89 years; SD, 9.8 years]; 71% male specimens) were dissected leaving the proximal humerus, proximal biceps tendon, and pectorals major insertion. Specimens were randomized 1 to 6 groups and a sub-pectoral biceps tenodesis was performed. The specimens underwent load to failure axial traction on a materials testing machine. Results: The mean failure loads with the 95%Cl are as follows: IS (78.6N, 58.1-99.1 N), ST (100.3 N, 77.7-122.9 N), DL-1.9 (120.6 N, 101.3-139.8 N), EB (136.7 N, 104.5-168.9 N), DL-2.9 (141.0 N, 111.3-170.7 N), and SL-1.7 (142.0 N, 107.9-176.1 N). Failure occurred at the tendon in almost all specimens, however 5 specimens sustained anchor failure during mechanical loading (IS, n=2; DL-2.9, n=1; DL-1.9, n=1; SL-1.7, n=1). Conclusion: The load to failure testing of the interference screw group demonstrated statistically significant lower results than the endobutton and anchor techniques. The endobutton and anchor techniques were not significantly different. The endobutton, double-loaded 2.9mm PEEK anchor, and single-loaded 1.7mm all-suture anchor attained the largest ultimate failure loads at approximately 140 N. These results may be taken into consideration when the orthopedic surgeon selects the appropriate fixation technique.

Background No study examining pin constructs has adequately addressed pin size and its role in fracture fixation. Our goal was to review our experience with Wilkins-modified Gartland type-III pediatric supracondylar humerus fractures treated with closed reduction and percutaneous pinning to evaluate the effects of pin size within 2 different pin constructs on maintenance of reduction and on the risk of surgical complications. Methods We retrospectively reviewed the medical records of pediatric patients with Wilkins-modified Gartland type-III supracondylar humerus fractures that were closed reduced and percutaneously pinned at our institution from March 1999 through December 2008. We grouped those 159 patients by fracture stabilization method (lateral-entry-pin or crossed-pin constructs), by pin size ratio (ie, ratio of pin diameter to the humeral midshaft cortical thickness: small ≤0.9; large >0.9), and then by 4 combinations of pin construct and pin size ratio. For each group, we evaluated radiographs for immediate postoperative reduction (coronal and sagittal alignment), maintenance of reduction at last follow-up, and the number of surgical complications. We used the Student t test, χ2 test, Mann-Whitney U test, and Wilcoxon Signed Rank test to examine for significance, which was set at P Results Although we found no significant differences between the groups immediately after surgery, final follow-up sagittal alignment was significantly more likely to be maintained in the large pin size ratio group than in the small pin size ratio group. For 2 types of surgical complications, infection and nerve palsy, we found no statistically significant differences in these complications between the pin construct or pin size ratio groups. Conclusions Large pin sizes improved radiographic sagittal alignment at final follow-up without an increased rate of infection or ulnar nerve palsy. Level of Evidence Level III Therapeutic Study.

Background: The utilization of peripheral nerve blocks in orthopaedic surgery has paralleled the rise in the number of ambulatory surgical procedures performed. Optimization of pain control in the perioperative orthopaedic patient contributes to improved patient satisfaction, early mobilization, decreased length of hospitalization, and decreased associated hospital and patient costs. Our purpose was to provide a concise, pertinent review of the use of peripheral nerve blocks in various orthopaedic procedures of the lower extremity, with specific focus on procedural anatomy, indications, patient outcome measures, and complications. Methods: We reviewed the literature and reference textbooks on commonly performed lower-extremity peripheral nerve block procedures in orthopaedic surgery, focusing on those most commonly used. Results: The use of lower-extremity peripheral nerve blocks is a safe and effective approach to perioperative pain management. Different techniques and timing can have an important impact on patient satisfaction, and each technique has specific indications and complications. For major hip surgery, one of the most commonly used is the lumbar plexus block, which can result in early mobilization, reduced postoperative pain, and decreased opioid-associated adverse events. Associated complications include epidural spread of anesthesia, retroperitoneal hematoma formation, and postoperative falls. For arthroscopic and open knee procedures, the femoral nerve block is frequently used adjunctively. It provides improved early postoperative pain control, early mobilization with therapy, and increased patient satisfaction compared with intra-articular or intravenous opioids alone; it also provides cost savings. However, some studies have shown no significant difference in outcome measures compared with intra-articular opioids alone for arthroscopic anterior cruciate ligament reconstruction. Associated complications include nerve injury, intravascular injection, and postoperative falls. Conclusions: The use of peripheral nerve blocks in lower-extremity surgery is becoming a mainstay of perioperative pain management strategy.

Background The Latarjet coracoid process transfer procedure is an established, reliable treatment for glenoid deficiency associated with recurrent anterior shoulder instability, but changes in neurovascular anatomy resulting from the procedure are a concern. The purpose of our cadaveric study was to identify changes in the neurovascular anatomy after a Latarjet procedure. Materials and methods We obtained 4 paired, fresh-frozen cadaveric forequarters (8 shoulders) from the Maryland State Anatomy Board. In each shoulder, we preoperatively measured the distances from the midanterior glenoid rim to the musculocutaneous nerve, axillary nerve, and axillary artery in 2 directions (lateral to medial and superior to inferior) and with the arm in 2 positions (0° abduction/neutral rotation; 30° abduction/30° external rotation), for a total of 12 measurements. We then created a standardized bony defect in the anterior-inferior glenoid, reconstructed it with the Latarjet procedure, and repeated the same measurements. Two examiners independently took each measurement twice. Inter-rater reliability was adequate, allowing pre-Latarjet measurements to be combined, averaged, and compared with combined and averaged post-Latarjet measurements by using paired Student t tests (significance, P ≤ .05). Results We found (1) significant differences in the location of the musculocutaneous nerve in the superior-to-inferior direction for both arm positions, (2) notably lax and consistently overlapping musculocutaneous and axillary nerves, and (3) an unchanged axillary artery location. Conclusions The Latarjet procedure resulted in consistent and clinically significant alterations in the anatomic relationships of the musculocutaneous and axillary nerves, which may make them vulnerable to injury during revision surgery.

Study design Retrospective morphometric population study. Objective To characterize pedicle and spinal canal morphology of the achondroplastic lower thoracic and lumbar vertebrae and to suggest dimensions for improving pedicle screw selection and placement. Summary of background data Although morphometric population studies exist for various races, to our knowledge, no such analysis has been made in achondroplastic patients. Methods With computer software, we measured pedicle parameters on the computed tomography images of 19 adult achondroplastic patients. Results Pedicle and chord lengths ranged from 9.5-12.5 mm and 29.5-36.4 mm, respectively. Transverse pedicle diameter increased from T9 (5.5 mm) to L5 (14.2 mm). Sagittal pedicle diameter declined from L1 (11.6 mm) to L5 (7.8 mm). Transverse angulation was greatest at L5 (15.7 degrees ) and smallest at T12 (1.1 degrees ). Pedicles were directed cranially at all levels, ranging from 3.8 degrees -15.6 degrees . Interpedicular distance and cross-sectional area were smallest at L4 (14.9 mm and 119 mm, respectively). Pedicle starting points diverged from T9 (13.6 mm) to L5 (19.2 mm2). Conclusion Achondroplastic pedicle morphology differs markedly from those of the normal spine: chord lengths are substantially shorter, pedicles are inclined cranially, pedicle starting points diverge progressively in the lumbar spine, and pedicle shape transitions from vertically to horizontally oriented ellipsoids along the lumbar spine. Consideration of this variation could maximize the effectiveness and safety of pedicle instrumentation.

When addressing the politics of sports medicine, it is often helpful to obtain the advice of people who work in the trenches and who have experiences that can be of benefit to clinicians in the field or who are contemplating going into the field. The goal of this project was to obtain advice from physicians who have dealt with these political issues. It is hoped that their insights will prove helpful for physicians and others who are involved in the care of athletes, regardless of the athlete's level of the play.

V ertebroplasty, first described by Galibert et al.1 for the treatment of vertebral angiomas, is now often used to treat painful osteoporotic compression fractures of vertebral bodies and the pain associated with malignant tumor osteolysis2,3. Vertebral augmentation with percutaneous injection of polymethylmethacrylate cement after the use of an inflatable bone tamp is a variant of vertebroplasty that is commonly called kyphoplasty, a term that we will use hereafter. Inflation of the balloon tamp elevates the vertebral body end plates to reduce kyphosis4-6. Although infrequent, the complications of these procedures include leakage of cement into perispinal areas or the epidural space, embolization of cement, and spinal infection. Cement leakage is responsible for neurologic complications, including transient radiculopathies and spinal cord compression2,7,8. Thermal necrosis is a well-established consequence of cement-curing in conjunction with arthroplasty9-11, but the role of the exothermic polymerization of polymethylmethacrylate in vertebroplasty is unknown. Temperatures measured in an ex vivo study were sufficiently high for thermal necrosis to be considered a possibility12,13. The authors of a histopathologic study14 attributed a zone of necrosis around polymethylmethacrylate cement that had been injected into a metastatic vertebral tumor to thermal necrosis, but there may be other causes. We are aware of only two previous postmortem human studies in which augmented vertebral bodies were analyzed histologically14,15. The aim of our study was to investigate histopathologically the response of vertebral bodies to augmentation with polymethylmethacrylate cement introduced in a kyphoplasty. Fig. 1 Lateral radiograph of a spine specimen, showing four vertebrae (T11, L2, L4, and L5) containing polymethylmethacrylate. Compression fractures can be seen in several other vertebrae. Aseventy-five-year-old man presented with multiple, extremely painful compression fractures of the …

Background The incidence of scapular winging is unclear, but it may be more common than previously thought. It can be difficult to diagnose because the presenting complaint and physical examination may direct the practitioner toward more common shoulder and neck conditions. Ongoing scapular dysfunction may result in inappropriate or failed surgery. Our goals were to (1) describe the common misdiagnoses (instability, labral abnormality, impingement, and cervical spine disease), the clinical scenarios and examination findings leading to diagnostic difficulty, the definitive treatment options available, and the clinical outcomes and complications; and (2) review the important aspects of the patient history, physical examination of the scapula, and associated studies necessary to make the correct diagnosis of scapular winging. Methods We reviewed the literature relative to, and our own experience with, the treatment of scapular winging and identified a series of patients with this condition who were initially misdiagnosed with other shoulder or spine abnormalities. In our literature search, only nine clinical studies reported on a series of patients with scapular winging that was initially misdiagnosed or had a delay in diagnosis (n = 53 patients). We examined these cases for presenting or preexisting diagnoses and for surgical procedures that had been performed before the diagnosis of scapular winging. Results For patients ultimately diagnosed with scapular winging, initial presentations and diagnoses included rotator cuff disorders (20%), glenohumeral instability (8%), peripheral nerve disorders (6%), cervical spine disease (6%), acromioclavicular disorders (6%), thoracic outlet syndrome (4%), and unknown or unspecified (41%). The most common surgical procedures performed before definitive scapular winging treatment were rotator cuff (22%), instability (22%), nerve (14%), acromioclavicular (12%), cervical spine (5%), and thoracic outlet (4%) procedures. Conclusions Clinically, scapular winging often mimics more common shoulder abnormalities and can result in unnecessary or unsuccessful surgical procedures. Diagnosis can be readily achieved with simple physical examination and specific provocative maneuvers in conjunction with electromyography and nerve conduction studies. Prompt diagnosis and recognition can avoid substantial shoulder dysfunction.

Background The utilization of peripheral nerve blocks in orthopaedic surgery has paralleled the rise in the number of ambulatory surgical procedures performed. Optimization of pain control in the perioperative orthopaedic patient contributes to improved patient satisfaction, early mobilization, decreased length of hospitalization, and decreased associated hospital and patient costs. Our purpose was to provide a concise, pertinent review of the use of peripheral nerve blocks in various orthopaedic procedures of the lower extremity, with specific focus on procedural anatomy, indications, patient outcome measures, and complications. Methods We reviewed the literature and reference textbooks on commonly performed lower-extremity peripheral nerve block procedures in orthopaedic surgery, focusing on those most commonly used. Results The use of lower-extremity peripheral nerve blocks is a safe and effective approach to perioperative pain management. Different techniques and timing can have an important impact on patient satisfaction, and each technique has specific indications and complications. For major hip surgery, one of the most commonly used is the lumbar plexus block, which can result in early mobilization, reduced postoperative pain, and decreased opioid-associated adverse events. Associated complications include epidural spread of anesthesia, retroperitoneal hematoma formation, and postoperative falls. For arthroscopic and open knee procedures, the femoral nerve block is frequently used adjunctively. It provides improved early postoperative pain control, early mobilization with therapy, and increased patient satisfaction compared with intra-articular or intravenous opioids alone; it also provides cost savings. However, some studies have shown no significant difference in outcome measures compared with intra-articular opioids alone for arthroscopic anterior cruciate ligament reconstruction. Associated complications include nerve injury, intravascular injection, and postoperative falls. Conclusions The use of peripheral nerve blocks in lower-extremity surgery is becoming a mainstay of perioperative pain management strategy.