Ajay Premkumar

Liposomal Bupivacaine for Pain Control After Anterior Cruciate Ligament Reconstruction A Prospective, Double-Blinded, Randomized, Positive-Controlled Trial

Background: Local anesthetics are commonly administered into surgical sites as a part of multimodal pain control regimens. Liposomal bupivacaine is a novel formulation of bupivacaine designed for slow diffusion of a single dose of local anesthetic over a 72-hour period. While early results are promising in various settings, no studies have compared pain management regimens containing liposomal bupivacaine to traditional regimens in patients undergoing anterior cruciate ligament (ACL) reconstruction. Purpose: To evaluate liposomal bupivacaine in comparison with 0.25% bupivacaine hydrochloride (HCl) for pain control after ACL reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 32 adult patients undergoing primary ACL reconstruction with a soft tissue quadriceps tendon autograft between July 2014 and March 2015 were enrolled. All patients received a femoral nerve block immediately before surgery. Patients then received either a 40-mL suspension of 20 mL Exparel (1 vial of bupivacaine liposome injectable suspension) and 20 mL 0.9% injectable saline or 20 mL 0.5% bupivacaine HCl and 20 mL 0.9% injectable saline, which was administered into the graft harvest site and portal sites during surgery. Patients were given either a postoperative smartphone application or paper-based journal to record data for 1 week after ACL reconstruction. Results: Of the 32 patients recruited, 29 patients were analyzed (90.6%). Two patients were lost to follow-up, and 1 was excluded because of a postoperative hematoma. There were no statistically significant differences in postoperative pain, medication use, pain location, recovery room time, or mobility between the 2 study groups. Conclusion: There were comparable outcomes with 0.25% bupivacaine HCl at a 200-fold lower cost than liposomal bupivacaine. This study does not support the widespread use of liposomal bupivacaine for pain control after ACL reconstruction in the setting of a femoral nerve block. Registration: ClinicalTrials.gov NCT02189317

Increasing Influenza Vaccination Rates among Hospital Employees without a Mandatory Policy

Rizvani R. Monitoring the effectiveness of hospital cleaning practices by use of adenosine triphosphate bioluminescence assay. Infect Control Hosp Epidemiol 2009;30:678-684. 7. Lewis T, Griffith C, Gallo M, Weinbren M. A modified ATP benchmark for evaluating the cleaning of some hospital environmental surfaces. / Hosp Infect 2008;69:156-163. 8. Turner DE, Daugherity EK, Altier C, Maurer KJ. Efficacy and limitations of an ATP-based monitoring system. / Am Assoc Lab Anim Sci 2010;49:190-195.

Pulse Generator Exchange Does Not Accelerate the Rate of Electrical Failure in a Recalled Small Caliber ICD Lead

St. Jude Riata/Riata ST defibrillator leads (St. Jude Medical, Sylmar, CA, USA) were recalled by the Food and Drug Administration in 2011 for an increased rate of failure. More than 227,000 leads were implanted and at least 79,000 patients still have active Riata leads. Studies have examined clinical predictors of lead failure in Riata leads, but none have addressed the effect of implantable cardioverter defibrillator (ICD) generator exchange on lead failure. The purpose of this study is to assess the effect of ICD generator exchange on the rate of electrical failure in the Riata lead at 1 year.

Clinical Outcomes of All Soft Tissue Quadriceps Tendon Autograft in ACL Reconstruction

Objectives: The quadriceps tendon (QT) autograft has been successfully utilized for anterior cruciate ligament (ACL) reconstruction for decades. While many studies have shown QT autografts are an effective graft choice, few have prospectively examined short and intermediate-term clinical outcomes following revision procedures. This study examines prospectively collected intermediate-term clinical outcomes, including complication rates, following primary ACL reconstruction with all soft tissue QT autograft. Methods: 353 patients undergoing primary ACL reconstruction with an all soft tissue QT autograft were prospectively followed. All procedures were performed by a single surgeon, utilizing a minimally invasive graft harvest technique and suspensory fixation. All patients received aggressive rehabilitation without functional bracing post-operatively. Subjective assessment of knee function was obtained using pre-operative and post-operative IKDC scores, with a minimum of 1-year follow-up. Postoperative KT-1000 arthrometer and isokinetic strength testing measurements were collected at regular intervals. The incidence of graft harvest site hematoma, arthrofibrosis, and graft failure were recorded. Results: The mean age of the study population was 20.4 ± 6.4 (mean ± SD) years, with an average follow up of 2.53 ± 1.04 years. Primary ACL reconstruction was performed in 353 patients. The patient population was approximately evenly split by gender with 27 male (56%) and 21 female (44%). and the preoperative mean IKDC score was 44.9 ± 15.5, and postoperative mean IKDC score was 85.2 ± 14.3, (p<0.0001). The percentage of patients with ≤3 mm side-to-side difference on KT-1000 arthrometer testing at 6-weeks, 3-months, and 6-months was found to be 97%, 96%, and 93%, respectively. No significant increase (p>0.05) in side-to-side measurements was found between the 6-week to 3-month or the 3-month to 6-month intervals. Isokinetic strength testing at 6 months post-operatively showed the mean extension torque at 60°/s and 180°/s was 75.2% and 80.3% respectively. These values increased significantly at 1 year to 86.1% (p<.0006) and 87.5% (p = .018). Graft harvest site hematoma developed in 11 patients (2.7%) and arthrofibrosis occurred in 30 (7.5%). Graft failure requiring revision occurred in 17 (4.2%) patients, with a mean time to revision procedure of 542 ± 210 days post-operatively. Conclusion: ACL reconstruction with an all soft tissue QT autograft using a minimally invasive harvest technique and suspensory fixation has acceptable short and intermediate-term clinical outcomes. No evidence of early graft failure or lengthening was discovered, confirming suspensory fixation is sufficient for aggressive rehabilitation in a young, athletic patient population. The low complication and failure rates in patients that received QT autograft for ACL reconstruction compare favorably to published data on alternate autograft options. The results of this study support the use of all soft tissue QT autograft in ACL reconstruction.

Adductor Canal vs. Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Objectives: Peripheral nerve blocks are commonly performed as a part of multimodal pain control regimens, especially for outpatient surgical procedures. Femoral nerve blocks (FNB) have been the traditional gold standard nerve block in the setting of ACL reconstruction; however, adductor canal blocks (ACB) have emerged as a promising alternative. While early findings show less quadriceps strength deficits following adductor canal blocks, results comparing analgesia from adductor canal nerve blockade to femoral nerve blockade are inconsistent. The purpose of this study was to compare adductor canal nerve block to femoral nerve block for pain control following ACL reconstruction. Methods: This study was a prospective, single-blinded, randomized, controlled, parallel single-center trial. 77 adult patients receiving ACL reconstruction were enrolled between December 2015 and April 2016. All patients received either a traditional FNB or an ACB immediately prior to surgery. All patients were given a post-operative smartphone application to record medication usage, pain scores, hours of sleep, and time to straight leg raise for one week following ACL reconstruction. Results: Of the 77 patients recruited, 64 patients were analyzed (83.1%). 13 patients were lost to follow-up. There were no statistically significant differences in post-operative pain, home medication use, recovery room time, or hours of sleep between the two study groups. Patients receiving an ACB had significantly shorter time to straight leg raise and reported greater satisfaction with acute post-operative pain control. Conclusion: Adductor canal nerve blockade had similar analgesic outcomes, improved post-operative mobility, and greater patient satisfaction with pain control than femoral nerve blockade. Our study supports the use of adductor canal block as a viable alternative to femoral nerve block following ACL reconstruction.