Harris S. Slone

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

The impact of race on the development of severe heterotopic ossification following acetabular fracture surgery

OBJECTIVES To determine the association between race on severe heterotopic ossification (HO) following acetabular fracture surgery. DESIGN Retrospective case control study. SETTING Level I university trauma centre. METHODS Two hundred and fifty-three patients who were surgically treated for acetabular fractures were retrospectively evaluated. Postoperative radiographs were evaluated for HO by a blinded musculoskeletal radiologist, and classified based on a modified Brooker classification. RESULTS Of the 253 patients that met inclusion and exclusion criteria, 175 (69%) were male and 78 (31%) were female. One hundred and fifty-four (61%) patients were Caucasian, and 99 (39%) were African American (AA). Fifty-five (21%) patients developed severe HO. Of those who developed severe HO, 25 were Caucasian (45%), 30 were African American (55%). Forty-one patients (75%) with severe HO were male, and 14 (25%) were female. No statistical differences (p>0.05) were found between groups in terms of age, days to surgery, GCS at presentation, surgical approach, perioperative HO prophylaxis, or AO/OTA fracture classification. The patient population was then stratified by race, gender, and race/gender. AA were more likely than Caucasians to develop severe HO (odds ratio [OR], 2.24; confidence interval [CI], 1.22-4.11). When gender was considered independent of race, no statistical differences (p>0.05) were observed (OR, 1.40; CI, 0.71-2.75). AA males were much more likely to develop severe HO when compared to Caucasian females (OR, 4.4; CI, 1.38-14.06). CONCLUSION Race is associated with different rates of severe HO formation following acetabular fracture surgery. AA patients are significantly more likely to develop severe HO following acetabular fracture surgery when compared to Caucasian patients.

Quadriceps tendon autograft for arthroscopic knee ligament reconstruction: use it now, use it often

Traditional bone-patellar tendon-bone and hamstring tendon ACL grafts are not without limitations. A growing body of anatomic, biomechanical and clinical data has demonstrated the utility of quadriceps tendon autograft in arthroscopic knee ligament reconstruction. The quadriceps tendon autograft provides a robust volume of tissue that can be reliably harvested, mitigating the likelihood of variably sized grafts and obviating the necessity of allograft augmentation. Modern, minimally invasive harvest techniques offer the advantages of low rates of donor site morbidity and residual extensor mechanism strength deficits. New data suggest that quadriceps tendon autograft may possess superior biomechanical characteristics when compared with bone-patella tendon-bone (BPTB) autograft. However, there have been very few direct, prospective comparisons between the clinical outcomes associated with quadriceps tendon autograft and other autograft options (eg, hamstring tendon and bone-patellar tendon-bone). Nevertheless, quadriceps tendon autograft should be one of the primary options in any knee surgeon’s armamentarium.

Acute versus staged surgical intervention in multiligamentous knee injuries: a review of the literature since 2009

Background:Our purpose was to determine whether recent literature provides evidence to favor either acute or staged surgical treatment of multiligamentous knee injury (MLKI). Because MLKI is uncommon and has a heterogeneous injury profile, conducting large trials has been challenging. Surgical intervention whether through repair or reconstruction is associated with high complication rates and significant morbidity. Currently, treatment recommendations are based on outcome studies composed mostly of level IV evidence. Methods:We searched the literature from 2009-2014. Eleven published studies met inclusion criteria. There were two level III studies and nine level IV studies. No level I studies met inclusion criteria. Results:Two-hundred seventy-four patients were identified; 201 males and 73 females. Thirty-nine percent (107) of the patients had a staged repair; 61% (167) of the patients had an acute repair. IKDC was the most consistently reported outcome measure, yet none of the studies reached statistical significance. Conclusions:Numerous studies have attempted to determine whether to repair or reconstruct the MLKI in an acute or a staged fashion. There is insufficient evidence to suggest superiority of outcomes for acute or staged treatment MLKI. Multicentered, prospective, randomized controlled trials are warranted to determine if there is any difference in outcomes between these two treatment strategies.

Economic impact of outreach athletic trainers on a health system: implications for program growth and sustainability

ABSTRACT Objectives: There are numerous benefits of organized athletics, but there is an inherent risk with competitive participation. The need for proper care for high school and community athletes can be met with comprehensive community sports medicine programs, and the employment of certified athletic trainers (AT-Cs). The benefit of clinic-based AT-C has been clearly demonstrated, but there has been little published on the economics of outreach AT-C serving directly in the community. Our hypothesis was that outreach AT-Cs are economically sustainable to an academic health system. Methods: Evaluation of clinical business generated from the outreach Sports Medicine AT-C program at our institution was performed from fiscal years 2012 to 2015 to determine new referrals, billable patient encounters (bpe), and corresponding revenue generated. Data were retrieved from an existing aggregate business analysis, including both professional billing and hospital billing; data were restricted to the fiscal year of the initial referral. Both new patients and patients with established care were identified. Total revenue was determined, as well as the distribution across clinical departments within our health system. Results: 8570 bpe resulted from 843 patients referred into the system, yielding

Preoperative Shoulder Injections are Associated with Increased Risk of Subsequent Revision Rotator Cuff Repair

2286,733 in total revenue. Of these, 187 were new patients, yielding 1602 bpe. Each patient generated an average of 10.17 bpe, by combining revenue across services; this yielded an average of

Predicted quadriceps vs. quadrupled hamstring tendon graft size using 3-dimensional MRI

2712 per patient generated through the AT-C program. Conclusion: Affiliation between a health system and community sports teams through an outreach AT-C program is an economically sustainable, symbiotic relationship. Additionally, there is not only a positive economic impact for sports medicine and orthopaedic providers but also a distinct benefit to the entire health system. This is the first study to demonstrate that an outreach AT-C program is financially sustainable and directly benefits the entire health system across many subspecialties.

Orthopedic In-Training Examination: An Analysis of the Sports Medicine Section—An Update

Objectives: Corticosteroid injections (CSI) are frequently utilized in the nonoperative management of rotator cuff tears. However, recent literature suggests that injections may reduce biomechanical strength of tendons and ligaments in animal models and increase the risk of postoperative infections following surgery. The goal of this study was to determine if the timing of CSI is associated with an increased risk of reoperation following primary rotator cuff repair (RCR). Methods: A retrospective analysis of claims data of privately-insured subjects from the MarketScan® database for the years 2010-2014 was conducted. A cohort of subjects aged 18-64 who were diagnosed with a rotator cuff tear and underwent repair in 2011 was identified. Multivariable logistic regression models were used to compare the odds of reoperation between groups. Results: A total of 4,959 subjects with an arthroscopic RCR were identified. Of this, 553 subjects required reoperation within the following 3 years (Table 1). Patients who had a CSI within 6 months preceding the RCR were at a much higher risk of undergoing reoperation (Figure 1): 0-3 months prior, AOR 1.536 (95% CI: 1.201 -1.965); 3-6 months, AOR 1.843 (95% CI: 1.362-2.494); and 6-12 months AOR 1.339 (95% CI: 0.914 -1.962). Of those patients that underwent a reoperation, the most common surgery performed was revision rotator cuff repair followed by arthroscopic debridement (48.5% versus 38.9% respectively). Conclusion: Patients who had received a CSI within 6 months prior to RCR were much more likely to undergo a subsequent reoperation within the following 3 years. These odds diminished as more time passed between CSI and primary repair. Consideration should therefore be given to delaying primary rotator cuff repair for 6 months following injection. Table 1. Listing of reoperations, by timing of last CSI prior to primary RCR Reoperation (CPT) No CSI 0-3 Months 3-6 Months 6-12 Months 12+ Months TOTAL (%) Arthroplasty 23470. Hemiarthroplasty 3 1 0 0 0 4(0.7) 23472. Arthroplasty 11 6 4 2 1 24(4.4) Arthroscopy 29805. Diagnostic 3 0 0 0 0 3(0.5) 29820. Synovectomy (Partial) 3 0 0 0 0 3(0.5) 29821. Synovectomy (Complete) 3 0 1 0 0 4(0.7) 29822. Debridement (Limited) 50 9 10 8 0 77(13.9) 29823. Debridement (Extensive) 87 30 15 6 0 138(25.0) 29825. With lysis and resection of adhesions 20 7 1 4 0 32(5.8) 29827, With Rotator Cuff Repair 178 44 30 14 2 268(48.5) 358 97 61 34 3 553 Figure 1. Odds of reoperation following primary rotator cuff repair (RCR) among those who received a corticosteroid injection (CSI) in the 12-months prior to surgery. Odds ratios are relative to the patients who did not receive a CSI in the 12-months prior to surgery.

New 5-Factor Modified Frailty Index Predicts Morbidity and Mortality in Primary Hip and Knee Arthroplasty

BACKGROUND The objective of this study is to (1) compare the predicted cross-sectional area and diameter between quadriceps tendon and quadrupled hamstring autografts, and (2) assess the predicted size of the quadriceps tendon graft in patients with hamstrings that are insufficient for use in ACL reconstruction. METHODS A retrospective review of 54 knee 3D MRIs was conducted. Quadriceps tendon graft area was defined as a one-centimeter wide area of quadriceps tendon, measured three centimeters above the patella perpendicular to tendon axis. Quadrupled hamstring graft area was defined as double the combined areas of the gracilis and semitendinosus tendon, measured three centimeters above the joint line perpendicular to tendon axis. Pearson correlation was used to compare the quadriceps tendon and quadrupled hamstring grafts. RESULTS Mean cross-sectional area of quadrupled hamstring and quadriceps tendon grafts were 47.2 mm2 and 84.4 mm2 respectively. A statistically significant positive correlation exists between quadrupled hamstring graft and quadriceps tendon graft cross-sectional area (r = 0.41; p = 0.002). Nine of the 54 patients had predicted quadrupled hamstring grafts deemed insufficient for use in ACL reconstruction (<8 mm diameter). All of these patients had predicted quadriceps tendon graft diameters >8 mm. CONCLUSION There is a positive correlation between predicted quadriceps tendon and quadrupled hamstring grafts. While 17% of patients in this series had predicted insufficient quadrupled hamstring grafts, all of the patients had predicted quadriceps tendon grafts of sufficient size for ACL reconstruction. Quadriceps tendon grafts are a viable alternative in patients at-risk for insufficient quadrupled hamstring grafts. LEVEL OF EVIDENCE IV.

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

OBJECTIVE Previously published studies have evaluated Orthopedic In-Training Examination sports medicine questions, but none have evaluated whether question difficulty has changed over time. DESIGN Sports medicine subsection questions between 2012 and 2016 were evaluated and compared with previously published data on Orthopedic In-Training Examination from 2004 to 2009. Question categories were classified into 1 of 3 taxonomy levels-basic recall, diagnosis, and advanced problem solving. SETTING Medical University of South Carolina; Charleston, SC, 29425; Institution. PARTICIPANTS Two residents evaluated the Sports Subsection questions separately. Then an attending physician evaluated the questions to resolve discrepancies. A statistician was used for analysis. RESULTS Utilization of imaging modalities averaged 37%, with 28% (11/39) of the questions containing 2 or more imaging modalities. There were increases in utilization of advanced problem-solving questions (45% vs. 27%, p = 0.002) and decreases in basic recall questions (49% vs. 67%, p = 0.008) compared with previously published data. CONCLUSIONS While the percentage of the Orthopedic In-Training Examination represented by sports medicine has remained relatively unchanged, there were fewer questions requiring residents to demonstrate simple recall and diagnosis, and increased demand to perform advanced problem solving while utilizing multiple imaging modalities.