James A. Hill

Bupivacaine use after knee arthroscopy: Pharmacokinetics and pain control study

Bupivacaine (Marcaine) pharmacokinetics were determined in 11 patients receiving the drug intraarticularly after arthroscopic procedures performed on the knee with patients under general anesthesia. Forty milliliters of 0.25% bupivacaine (100 mg) were given as a bolus into the intraarticular space of the knee of each patient. The thigh tourniquet was released 2-3 min after injection and blood samples were obtained 5, 10, 15, 20, 30, 60, 120, 180, 250, and 300 min after tourniquet release. Pharmacokinetic parameters obtained were (mean +/- SD): Vd beta 206 +/- 88 L; Cle 0.816 +/- 0.378 L/min; t 1/2 beta 189 +/- 84 min; ka 9.92 +/- 6.79 x 10/min; Cpmax 0.48 +/- 0.20 micrograms/ml; and tmax 43.4 +/- 23.1 min. Correlations between higher peak plasma concentrations and longer tourniquet times (p = 0.02) and shorter intervals from injection to tourniquet deflation (p = 0.03) were found using multiple linear regression. Our results indicate that injections of 100 mg of bupivacaine intraarticularly after knee arthroscopy will produce peak blood levels within the 1st h after surgery and that these levels will be well below those noted to produce toxic reactions. Peak levels can be minimized with shorter tourniquet inflation times and with longer injection to tourniquet release intervals. Ninety healthy adult outpatient knee arthroscopy patients also were studied to evaluate the effectiveness of bupivacaine in relieving postoperative knee discomfort when injected immediately postoperatively. The subjects were randomized into four groups: (a) intraarticular injection of saline, (b) intraarticular injection of bupivacaine, (c) subcutaneous injection of bupivacaine at the portal sites, and (d) both intraarticular and subcutaneous injection of bupivacaine.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous Achilles tendon repair

Fourteen patients underwent percutaneous Achilles tendon repairs between 1982 and 1989 for ruptures approximately 2 to 8 cm from the calcaneal insertion. They were evaluated subjectively (questionnaires) and objectively (physical examinations, Cybex II dynamom eter). The minimum follow-up time was 2 years with an average of 3.8 years. Subjectively, all of the patients were satisfied with their overall results. Objectively, no significant difference was demonstrated by Cybex II evaluation at 60 and 120 deg/sec. A significant differ ence was seen at 180 deg/sec, but this represented only a 13% loss of power. No infections, delayed wound healing, reruptures, or evidence of thrombophlebitis were noted. There was one sural nerve injury.

The modified Bristow-Helfet procedure for recurrent anterior shoulder subluxations and dislocations

A review of 107 cases in which the Bristow-Helfet procedure was done for recurrent anterior shoulder subluxation and dislocation is presented. The redis location rate was 2% with very few complications. Eighty-nine percent of the patients were satisfied with the procedure. Mean loss of external rotation was 12.6°. Six of the 41 patients with dominant shoulder surgery were capable of throwing in the same manner as they did prior to injury. Five of 24 patients (21 %) with a diagnosis of recurrent anterior subluxation con tinued to have symptoms of instability following sur gery. Associated symptoms of posterior or voluntary subluxation may preclude a satisfactory result.

Knee Joint Motion and Ligament Forces Before and After ACL Reconstruction

The goal of this in vitro study was to investigate the initial postoperative mechanical state of the knee with various types of anterior cruciate ligament (ACL) reconstructions. An experimental knee testing system was developed for the in vitro measurement of ligament forces and three-dimensional joint motion as external loads were applied to fresh knee specimens. Two groups of knee specimens were tested. In test series #1, two intraarticular reconstructions were performed in each of five specimens using semifree and free patellar tendon grafts with bone blocks. In test series #2, a more carefully controlled intraarticular reconstruction was performed in five specimens using a semifree composite graft consisting of the semitendinosus and gracilis tendons augmented with the Ligament Augmentation Device. Ligament force and joint motion data were collected as anteriorly directed tibial loads were applied to the normal joint, the joint with a cut ACL and the reconstructed joint. These knee joint states were compared on the basis of ACL or graft forces, joint motion and load sharing by the collateral ligaments. The dominate result of the study was that the forces and motions defining the mechanical state of the knee after the ACL reconstructions in both test series were highly variable and abnormal when compared to the normal knee state. The higher level of surgical control series #2 did not decrease this variability. There was a poor correlation between motion of the reconstructed knee relative to normal, and the ACL graft force. There was little consistent difference in force and motion results between the surgical procedures tested.

Complications of posterolateral dislocation of the knee: case report and literature review.

A 49-year-old man incurred a posterolateral dislocation of the knee, a rare type of knee injury. The injury was associated with a significant skin slough as a result of internal pressure from the displaced medial femoral condyle. The dislocation also was associated with a rupture of the quadriceps tendon. The mechanism of injury was a forcible abduction of the flexed knee, coupled with medial rotation of the tibia upon the femur. This type of knee dislocation cannot be reduced closed and therefore immediate open reduction with primary ligamentous repair is the treatment of choice.

Improving residency training in arthroscopic knee surgery with use of a virtual-reality simulator: A randomized blinded study

BACKGROUND There is a paucity of articles in the surgical literature demonstrating transfer validity (transfer of training). The purpose of this study was to assess whether skills learned on the ArthroSim virtual-reality arthroscopic knee simulator transferred to greater skill levels in the operating room. METHODS Postgraduate year-3 orthopaedic residents were randomized into simulator-trained and control groups at seven academic institutions. The experimental group trained on the simulator, performing a knee diagnostic arthroscopy procedure to a predetermined proficiency level based on the average proficiency of five community-based orthopaedic surgeons performing the same procedure on the simulator. The residents in the control group continued their institution-specific orthopaedic education and training. Both groups then performed a diagnostic knee arthroscopy procedure on a live patient. Video recordings of the arthroscopic surgery were analyzed by five pairs of expert arthroscopic surgeons blinded to the identity of the residents. A proprietary global rating scale and a procedural checklist, which included visualization and probing scales, were used for rating. RESULTS Forty-eight (89%) of the fifty-four postgraduate year-3 residents from seven academic institutions completed the study. The simulator-trained group averaged eleven hours of training on the simulator to reach proficiency. The simulator-trained group performed significantly better when rated according to our procedural checklist (p = 0.031), including probing skills (p = 0.016) but not visualization skills (p = 0.34), compared with the control group. The procedural checklist weighted probing skills double the weight of visualization skills. The global rating scale failed to reach significance (p = 0.061) because of one extreme outlier. The duration of the procedure was not significant. This lack of a significant difference seemed to be related to the fact that residents in the control group were less thorough, which shortened their time to completion of the arthroscopic procedure. CONCLUSIONS We have demonstrated transfer validity (transfer of training) that residents trained to proficiency on a high-fidelity realistic virtual-reality arthroscopic knee simulator showed a greater skill level in the operating room compared with the control group. CLINICAL RELEVANCE We believe that the results of our study will stimulate residency program directors to incorporate surgical simulation into the core curriculum of their residency programs.

A new method of patellectomy for patellofemoral arthritis.

Total patellectomy, although it has a biomechanical disadvantage in that it may lead to a degree of quadriceps weakness, is frequently indicated in selected patients. Numerous different techniques of performing patellectomy have been described. In this paper, we present a technique of performing a patellectomy in which the continuity of the quadriceps mechanism is not disrupted and the vastuc medialis is advanced. Twenty-six patients (twenty-nine knees) in whom the procedure was performed were studied retrospectively. The findings in this series showed 90 per cent good or excellent results, two cases of extensor lag, an average of 118 degrees of knee flexion, minimum quadriceps atrophy with good strength, and minimum postoperative immobilization. The method presented has the important advantage of an easier, smoother postoperative knee-rehabilitation period, which is extremely advantageous in elderly patients.

The athletic polydrug abuse phenomenon A case report

A case of a power weight lifter who is ingesting large doses of anabolic steroids plus other drugs to counter act their short-term side effects is presented. This type of polydrug abuse phenomenon which is unique to the competitive athlete is widespread despite the lack of convincing evidence that anabolic steroids increase muscular strength. The vast extent of this drug abuse problem is poorly appreciated by the gen eral medical community. The potential complications of the long-term usage of these drugs such as liver failure, hepatocellular car cinoma, and peliosis hepatitis make these drugs ex tremely dangerous.

Personal perception on mentoring.

The current authors discuss mentoring as an important volunteer activity. The roles and responsibilities of the mentor and the protégé are described. The mentors role consists of teaching, coaching, supporting, counseling, and sharing information with the protégé. The protégé responsibilities are to understand the value of the mentor and seek his or her advice. The importance of mentoring underrepresented minorities, potential and present medical students in orthopaedic surgery is specifically described. The personal experience of one author is given as an example of what can be accomplished and why the current authors think mentoring is important.

An unusual complication of minidose heparin therapy.

A 50-year-old woman developed a massive hematoma of the superficial abdominal wall following subcutaneous heparin therapy. The lesion was located above the fasica, became infected, and was associated with epithelial necrosis over the right lower quadrant of the abdominal wall. Operative excision of the entire affected area with primary closure was successful 4 weeks following the injection. The etiology of this problem was attributed to accidental laceration of the superficial epigastric vessels. This extensive local complication of subcutaneous minidose heparin injection seems not to have been previously reported.