Donald H. Johnson

Effect of preemptive multimodal analgesia for arthroscopic knee ligament repair.

Background and Objectives Administration of analgesic medication before surgery, rather than at the completion of the procedure, may reduce postoperative pain. Similarly, administration of multiple analgesics, with different mechanisms of action, may provide improved postoperative pain control and functional recovery. The purpose of our study was to compare pain scores and intravenous opioid consumption after outpatient anterior cruciate ligament (ACL) reconstruction in patients who received a multimodal drug combination (intravenous [IV] ketorolac, intra-articular morphine/ropivacaine/epinephrine, and femoral nerve block with ropivacaine) either before surgery or immediately at the completion of the surgical procedure. Methods Forty patients presenting for same-day arthroscopic ACL repair using a semitendinosis tendon graft were included in this study. The patients were randomized to receive the following drugs either 15 minutes before skin incision or immediately after skin closure: (1) Ketorolac 30 mg IV. (2) Intra-articular injection of 20 mL ropivacaine 0.25% + morphine 2 mg and epinephrine 1:200,000. (3) Femoral nerve block with 20 mL ropivacaine 0.25%. Verbal pain scores were obtained in the postanesthesia care unit (PACU) and on postoperative days 1, 3, and 7. IV patient controlled analgesia (PCA) morphine consumption in the PACU was also recorded. Results Verbal pain rating scores were lower in group I (preemptive) for 2.0 hours after arrival in the PACU. There was no difference between groups in pain scores on postoperative days 1, 3, and 7. Mean IV PCA morphine consumption in the PACU was lower in group I (6.4 mg) versus group II (12.3 mg), P < .05. Conclusion Preemptive, multimodal administration of our 3-component analgesic drug combination resulted in lower pain scores during the initial stay in the PACU unit and lower consumption of IV PCA morphine in the PACU. However, pain scores were similar in both groups on postoperative days 1, 3, and 7; thus, there was no measurable long-term advantage associated with preemptive multimodal drug administration.

Initial evaluation of posterior cruciate ligament injuries: history, physical examination, imaging studies, surgical and nonsurgical indications.

Compared with anterior cruciate ligament injuries, posterior cruciate ligament injuries are a rare event. The mechanisms are predictable and a thorough physical examination is mandatory to rule out or define combined injury patterns. Stress radiography and magnetic resonance imaging studies are very helpful adjuncts. Acute and chronic injuries require slightly different approaches. As our understanding of normal and pathologic knee joint kinematics develops, nonoperative rehabilitation goals and operative techniques continue to evolve.

Evolving concepts in tunnel placement.

Tunnel placement in anterior cruciate ligament reconstruction has continued to evolve over time. The aim of this article is to review this evolution and comment on the senior authors current preferred technique. Initially, tunnels were dependent on the technique available, and isometry was felt to be important. Now, trying to reproduce the anatomy is preferred. Surgical technique has evolved from open surgery, with large anterior approaches, to arthroscopic two-incision outside-in techniques. After that, the evolution has led to the transtibial technique with one incision, then back to two incisions using the anteromedial portal, and finally, no incisions with the “all-inside technique.” Anatomic, biomechanical, and clinical studies have shown that using the footprint as the site for tunnels restores the native anterior cruciate ligament kinematics and controls not only anteroposterior translation, but also rotational motion. Surgeons should evolve their techniques, as science does, to improve results and give better care to their patients.

High failure rate for electrothermal shrinkage of the lax anterior cruciate ligament: a multicenter follow-up past 2 years.

PURPOSE The purpose of this study was to prospectively evaluate the midterm results (beyond 2 years) of thermal shrinkage on both lax native anterior cruciate ligament (ACL) and lax reconstructions and determine the effectiveness of this procedure. METHODS This is a multicenter study in which 64 patients from 2 sites underwent electrothermal shrinkage for a lax ACL, both native and previous reconstructions. They were followed up past 2 years with KT-1000 measurements (MEDmetric, San Diego, CA). Failure criteria included subsequent operations for instability or KT-1000 measurements greater than 5 mm. Three patients were lost to follow-up. RESULTS Among the 61 patients followed up past 2 years, failure occurred in 31 (50.8%). The failure rate for lax grafts alone was 78.9%, and there was a failure rate of 38.1% for lax native ligaments. CONCLUSIONS Electrothermal shrinkage of lax native or reconstructed ACLs is not an appropriate treatment.

A case report of cervical spine fracture with lap-shoulder belt restraints*

During an automobile crash a passenger, restrained by a lap and shoulder belt, sustained a fracture of the second cervical vertebra. Based on reported cases of lumbar spine seat belt injuries, a mechanism of this cervical injury is proposed. On extreme hyperflexion, an anterior wedge compression fracture of the cervical spine resulted, since the axis of rotation was through the vertebral body. In this situation, the fixation of the upper torso by the shoulder belt moves the axis of rotation forward, and a distractive force disrupts the posterior elements and produced a fracture through the lamina and pedicle of C2. The purpose of the presentation is not to decry the use of lap and shoulder belts but to alert physicians to the possible occurrence of cervical spine fractures in restrained occupants involved in automobile collisions.

The medical perspective of the Kona Ironman Triathlon.

The Kona Ironman Triathlon is one of the most difficult endurance races in the world. The medical director of this race has summarized his experience in managing the injuries that these triathletes suffer. The heat, strong winds, and overall length of the event present unique injuries in swimming, cycling, and running. These injuries and their management have evolved over the years, and the change in their treatment is discussed.

Strength and conditioning for triathletes.

Strength exercises for the knee, shoulder, and the core are essential to help prevent injuries to triathletes. This article will outline the most common exercises to strength the major joints and flexibility exercises to maintain range of motion of the joints.

Hamstring Harvest Technique for Anterior Cruciate Ligament Reconstruction

Traditional hamstring harvest of the semitendinosis and/or gracilis tendons may typically be performed through a limited 2-3 cm anteromedial incision. After isolation and distal release of the individual tendon(s), careful mobilization is performed to remove adjacent attachments, particularly at the medial head of the gastrocnemius. Tendon stripping releases the tendon proximally, and graft preparation and sizing are undertaken for subsequent ligament reconstruction.

Current Status on Synthetic Grafts

Historically, synthetic grafts have been associated with inconsistent functional outcomes and synovitis, effusions, and pseudoseptic reaction related to particulate debris. Newer generation designs may reflect lower complication profiles based on limited studies. Primary ligament repair with biologic scaffolds and/or synthetic augmentation may also offer promising results in selected patient subsets.

Editorial Commentary: A Revisit of an Old Clinical Dilemma—To Operate or Not to Operate on Acute Knee Anterior Cruciate Ligament Injuries

There is a feeling among knee surgeons that operating on an acute anterior cruciate ligament injury will increase the incidence of arthrofibrosis. A recent systematic review and meta-analysis of 7 recent articles compared early versus delayed anterior cruciate ligament reconstruction. The conclusions were that the clinical and stability results were comparable in both groups.