Jeffrey Kay

Examining the Role of Perioperative Nerve Blocks in Hip Arthroscopy: A Systematic Review

PURPOSE This systematic review examined the efficacy of perioperative nerve blocks for pain control after hip arthroscopy. METHODS The databases Embase, PubMed, and Medline were searched on June 2, 2015, for English-language studies that reported on the use of perioperative nerve blocks for hip arthroscopy. The studies were systematically screened and data abstracted in duplicate. RESULTS Nine eligible studies were included in this review (2 case reports, 2 case series, 3 non-randomized comparative studies, and 2 randomized controlled trials). In total, 534 patients (534 hips), with a mean age of 37.2 years, who underwent hip arthroscopy procedures were administered nerve blocks for pain management. Specifically, femoral (2 studies), fascia iliaca (2 studies), lumbar plexus (3 studies), and L1 and L2 paravertebral (2 studies) nerve blocks were used. All studies reported acceptable pain scores after the use of nerve blocks, and 4 studies showed significantly lower postoperative pain scores acutely with the use of nerve blocks over general anesthesia alone. The use of nerve blocks also resulted in a decrease in opioid consumption in 4 studies and provided a higher level of patient satisfaction in 2 studies. No serious acute complications were reported in any study, and long-term complications from lumbar plexus blocks, such as local anesthetic system toxicity (0.9%) and long-term neuropathy (2.8%), were low in incidence. CONCLUSIONS The use of perioperative nerve blocks provides effective pain management after hip arthroscopy and may be more effective in decreasing acute postoperative pain and supplemental opioid consumption than other analgesic techniques. LEVEL OF EVIDENCE Level IV, systematic review of Level I to Level IV studies.

Level of clinical evidence presented at the International Society for Hip Arthroscopy Annual Scientific Meeting over 5 years (2010-2014).

The International Society for Hip Arthroscopy (ISHA) Annual Scientific Meeting is at the forefront of informing today’s orthopaedic surgeons and society of the rapid advances in the exponentially growing field of hip arthroscopy. The purpose of this study was to evaluate and observe any trends in the level of clinical evidence in the papers and posters presented at the ISHA Annual Scientific Meeting from 2010 to 2014. The online abstracts of the paper and poster presentations presented at the ISHA Annual Scientific Meetings were independently evaluated by two reviewers (582 total resulting presentations). Two reviewers screened these results for clinical studies and graded the quality of evidence from level I (i.e. randomized trials) to IV (i.e. case series) based on the American Academy of Orthopaedic Surgeons classification system. Four hundred and twenty-eight presentations met the inclusion criteria and were evaluated. Overall, 10.1% of the presentations were level I, 12.8% were level II, 30.1% were level III and 47.0% were level IV evidence. Over time, from 2010 to 2014, we observed an increase in the percentage of level II paper presentations, an increase in the proportion of level III poster presentations, and a decrease in the proportion of both level IV paper and poster presentations. Significant non-random improvement in the level of evidence presented was noted for the poster presentations (P = 0.012) but not for the paper presentations (P = 0.61) over the study period. Statistical trends demonstrate ISHA’s increased awareness and commitment to presenting higher quality evidence as the availability of this evidence increases.

Level of Clinical Evidence Presented at the Arthroscopy Association of North America Annual Meeting Over 10 Years (2006-2015).

PURPOSE To evaluate any trends in the level of clinical evidence in the papers presented at the Arthroscopy Association of North America (AANA) annual scientific meetings from 2006 to 2015. METHODS The online abstracts of the paper presentations presented at the AANA meetings were independently evaluated by 2 reviewers (664 total presentations). The reviewers independently screened these results for clinical studies and graded their level of evidence from Level I (i.e., randomized trials) to IV (i.e., case series) based on the American Academy of Orthopaedic Surgeons classification system. RESULTS Five hundred thirteen presentations met the inclusion criteria and were evaluated. Overall, 16% of the presentations were Level I evidence, 15% were Level II, 26% were Level III, and 43% were Level IV. We observed a significant non-random improvement in the level of evidence of presentations at the AANA meetings (P ≤ .001) between 2006 and 2015. In particular, the percentage of papers with Level IV evidence presented significantly decreased (P ≤ .001) and the percentage of papers with Level III evidence increased (P = .004) over the study period. CONCLUSIONS Statistical trends show that the influence of evidence-based medicine in orthopaedics has had a positive impact on the quality of research presented at the AANA meetings. LEVEL OF EVIDENCE Level IV, review of abstracts of Level I to Level IV evidence.

The h-Index of Editorial Board Members Correlates Positively With the Impact Factor of Sports Medicine Journals

Background: The h-index is a metric widely used to present both the productivity and impact of an author’s previous publications. Purpose: To evaluate and observe any correlations among the h-indices of 2015 editorial board members from 8 top sports medicine journals. Study Design: Systematic review. Methods: The sex, country of residence, degree, and faculty position of the editorial board members were identified using their respective scientific publication profiles. The h-index and other bibliometric indicators of these editorial board members were obtained using both the Web of Science (WoS) and Google Scholar (GS) databases. Nonparametric statistics were used to analyze differences in h-index values, and regression models were used to assess the ability of the editorial board member’s h-index to predict their journal’s impact factor (IF). Results: A total of 422 editorial board members were evaluated. The median h-index of all editors was 20 (interquartile range [IQR], 19) using GS and 15 (IQR, 15) using WoS. GS h-index values were 1.19 times higher than WoS, with significant correlation between these values (r 2 = 0.88, P = .0001). Editorial board members with a PhD had significantly higher h-indices than those without (GS, P = .0007; WoS, P = .0002), and full professors had higher h-indices than associate and assistant professors (GS, P = .0001; WoS, P = .0001). Overall, there were significant differences in the distribution of the GS (P < .0001) and WoS (P < .0001) h-indices of the editorial board members by 2014 IF of the journals. Both the GS h-index (β coefficient, 0.01228; 95% CI, 0.01035-0.01423; P < .0001) as well as the WoS h-index (β coefficient, 0.01507; 95% CI, 0.01265-0.01749; P < .0001) of editorial board members were significant predictors of the 2014 IF of their journal. Conclusion: The h-indices of editorial board members of top sports medicine journals are significant predictors of the IF of their respective journals.

Biomarkers in the serum, synovial fluid and articular cartilage show promising utility in patients with femoroacetabular impingement: a systematic review

Importance Biomarkers have promising potential to provide a cost-effective tool to identify patients with femoroacetabular impingement (FAI) who are most at risk and who may benefit most from early joint preservation surgery. Objective To assess the potential role of biomarkers in the diagnosis and prognosis of FAI. Evidence review Three databases (PubMed, Ovid (MEDLINE) and Embase) were searched on 20 August 2017 from database inception, and two reviewers independently and in duplicate screened the resulting literature. Methodological quality of all included papers was assessed using the Methodological Index for Non-Randomized Studies criteria. The results are presented in a narrative summary fashion using descriptive statistics including means, proportions and ranges. Findings Seven studies (one retrospective laboratory series and six controlled laboratory studies) were identified including a total of 227 patients. The mean age of the patients was 41.6 years (range: 13–80), with a mean follow-up period of 29.9 months (SD=3.2). Markers of articular cartilage breakdown, including cartilage oligomeric matrix protein (COMP) and fibronectin–aggrecan complex (FAC), were identified in high concentrations in the serum and synovial fluid of patients with FAI, respectively. Moreover, mRNA expression of catabolic cytokines in the articular cartilage of patients with FAI has been reported. Conclusions and relevance Although not yet used in clinical settings, several biomarkers of articular cartilage damage have been identified in the serum, synovial fluid and articular cartilage of patients with FAI. These findings provide promising insight into the potential role of biomarkers in guiding clinical practice and assisting with patient selection and preoperative counselling in patients with FAI and should be evaluated further. Level of evidence IV, systematic review of level III and IV studies.

Level of clinical evidence presented at the open and closed American Shoulder and Elbow Surgeons annual meeting over 10 years (2005–2014)

BackgroundThe American Shoulder and Elbow Surgeons (ASES) annual scientific meetings are premier forums whereby orthopaedic surgeons are informed of the latest research advances in shoulder and elbow surgery. The purpose of the present study was to assess the Level of evidence (LOE) in the clinical papers presented at both the open and closed ASES annual scientific meetings from 2005 to 2014. Secondarily, the study evaluated whether there were any changes in the distribution of LOE over this period of time.MethodsTwo reviewers independently evaluated the abstracts of 532 paper presentations at either the open or closed ASES annual meetings. The independent reviewers first screened the abstracts for clinical evidence and excluded cadaveric, biomechanical, technique, and review studies. The included abstracts were then independently graded for methodological quality using LOE from Level I (highest quality) to IV (lowest quality) based on the classification system created by The American Academy of Orthopaedic Surgeons (AAOS).ResultsOverall, 421 presentations were included and graded for LOE. In general, 17% of the presentations were graded level I; 15% level II; 25% level III; and 43% assigned a LOE of IV. Chi-square analysis demonstrated a statistically significant improvement in the LOE of presentations at the open and closed ASES meetings combined (p = 0.028) between the years 2005 and 2014. In particular, the proportion of presentations graded as level IV significantly decreased over this period (p = <0.001).ConclusionsWhile most presentations at the ASES annual scientific meetings were of lower LOEs the percentage of level I evidence is greater than that reported at other Orthopaedic meetings. There has been a significant improvement in the LOE of clinical research at open and closed ASES meetings from 2005 to 2014. Specifically, the proportion of level IV studies have dramatically decreased over time.

Arthroscopic-Assisted Latissimus Dorsi Tendon Transfer for Massive Rotator Cuff Tears: A Systematic Review:

Background: Arthroscopic-assisted latissimus dorsi tendon transfer (LDTT) has shown promising results with good outcomes in patients with massive rotator cuff tears (MRCTs), as reported by individual studies. However, to the best of the authors’ knowledge, no systematic review has been performed to assess the collective outcomes of these individual studies. Purpose/Hypothesis: The primary purpose of this study was to assess patient outcomes after arthroscopic-assisted LDTT for the management of MRCTs. The secondary objectives were to report on the management of MRCTs, including diagnostic investigations, surgical decision making, and arthroscopic techniques, as well as to evaluate the quality of evidence of the existing literature. It was hypothesized that nearly all patients were satisfied with arthroscopic-assisted LDTT and that they experienced improvements in pain symptoms, function, and strength after the procedure, with an overall complication rate of less than 10%. Study Design: Systematic review; Level of evidence, 4. Methods: The databases MEDLINE, Embase, and PubMed were searched from database inception (1946) until August 18, 2017, with titles, abstracts, and full-text articles screened independently by 2 reviewers. Inclusion criteria were English-language studies investigating arthroscopic-assisted LDTT for the management of MRCTs on patients of all ages. Conference papers, book chapters, review articles, and technical reports were excluded. The quality of the included studies was categorized by level of evidence and the Methodological Index for Non-Randomized Studies (MINORS) checklist. Results: In total, 8 studies (7 case series [median MINORS score, 7 of 16] and 1 prospective comparative study [median MINORS score, 14 of 24]) were identified; the studies included 258 patients (258 shoulders) with MRCTs treated with LDTT using arthroscopic-assisted techniques. The decision to pursue surgery was based on both clinical findings and investigations in 5 studies, investigations only in 2 studies, and clinical findings only in 1 study. Overall, 88% of patients were satisfied with the results of surgery and experienced significant improvement in their symptoms, including shoulder pain, strength, range of motion, and overall function, over a mean follow-up period of 34.3 months. Overall, there was a low rate of complications (7%) associated with the procedure. Conclusion: Arthroscopic-assisted LDTT for MRCTs provides patients with marked improvement in shoulder pain, strength, and function, and the procedure is associated with a low risk of complication. Further high-quality comparative studies are warranted to validate these findings in comparison with other operative techniques.

Fluid Extravasation in Shoulder Arthroscopic Surgery: A Systematic Review:

Background: Arthroscopic surgery of the shoulder joint has become increasingly more common given its advantages over open surgery; however, one rare but potentially life-threatening complication is fluid extravasation into the surrounding tissues, causing edema, respiratory compromise, abnormal results on laboratory blood tests, and possibly death. Currently, no systematic review exists that summarizes the existing clinical research on this topic. Purpose: To perform a systematic review on fluid extravasation as a complication of shoulder arthroscopic surgery, specifically assessing clinical presentation, risk factors, management, and outcomes. Study Design: Systematic review; Level of evidence, 4. Methods: Two reviewers independently searched 3 databases (PubMed, Ovid [MEDLINE], and Embase) from database inception until July 1, 2017. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist guided the reporting and data abstraction. The methodological quality of these studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) checklist. The results are presented in a narrative summary fashion using descriptive statistics including ranges and agreement statistics. Results: A total of 26 studies (20 case reports, 4 case series, and 2 prospective comparative studies) encompassing 205 patients (mean age, 50.8 years [range, 15-83 years]) were included. The most common signs of fluid extravasation included chest wall swelling (n = 86) and neck swelling (n = 116). In 32 patients, observation alone was sufficient. Other patients required airway intubation (n = 16), diuretics (n = 7), steroids (n = 1), and percutaneous drainage of fluid (n = 1). Clinical edema resolved after 2 to 48 hours, and patients were discharged 1 to 20 days postoperatively. Serious complications included transfer to the intensive care unit (n = 14), anterior interosseous nerve palsy (n = 4), rhabdomyolysis (n = 1), and death (n = 1). Conclusion: Fluid extravasation has the potential to be a life-threatening complication of shoulder arthroscopic surgery; however, it is most commonly managed nonoperatively, and symptoms typically resolve with no evidence of long-term complications. Intraoperative surgical decisions, such as minimizing the surgical time and volume of irrigation fluid used, may limit fluid extravasation, while careful intraoperative monitoring may facilitate prompt diagnosis and management to optimize patient outcomes.

Return to sport following arthroscopic Bankart repair: a systematic review

HYPOTHESIS AND BACKGROUND The purpose of this systematic review was to determine the return-to-sport rate following arthroscopic Bankart repair, and it was hypothesized that patients would experience a high rate of return to sport. METHODS The MEDLINE, Embase, and PubMed databases were searched by 2 reviewers, and the titles, abstracts, and full texts were screened independently. The inclusion criteria were English-language studies investigating arthroscopic Bankart repair in patients of all ages participating in sports at all levels with reported return-to-sport outcomes. A meta-analysis of proportions was used to combine the rate of return to sport using a random-effects model. RESULTS Overall, 34 studies met the inclusion criteria, with a mean follow-up time of 46 months (range, 3-138 months). The pooled rate of return to participation in any sport was 81% (95% confidence interval [CI], 74%-87%). In addition, the pooled rate of return to the preinjury level was 66% (95% CI, 57%-74%) (n = 1441). Moreover, the pooled rate of return to a competitive level of sport was 82% (95% CI, 79%-88%) (n = 273), while the pooled rate of return to the preinjury level of competitive sports was 88% (95% CI, 66%-99%). CONCLUSION Arthroscopic Bankart repair yields a high rate of return to sport, in addition to significant alleviation of pain and improved functional outcomes in the majority of patients. However, approximately one-third of athletes do not return to their preinjury level of sports.

Diagnostic Accuracy of Physical Examinations for ACL Injury

The three common physical examinations that are used to aid in the diagnosis of anterior cruciate ligament (ACL) injury are the anterior drawer test, Lachman’s test, and the pivot shift test. The anterior drawer test is the oldest and easiest maneuver to learn; however, various limitations contribute to a relatively low accuracy of this examination. The poor sensitivity of the anterior drawer test is improved when anesthesia is used and for patients with chronic, rather than acute, ACL injuries. Lachman’s test has the highest sensitivity of all three tests and is useful for ruling out complete ACL ruptures with a negative test result. The specificity of Lachman’s test is high, but the pivot shift test has the highest specificity of all three physical examinations. Thus a positive pivot shift test is most accurate in diagnosing an ACL insufficiency. Studies, particularly those before the year 2000, indicate that a negative pivot shift test does not provide useful information for exclusion, and improved results of the test performed with anesthesia indicate that these false-negative results are partially caused by muscle guarding.