Michael Drexler

Is There a Benefit for Liposomal Bupivacaine Compared to a Traditional Periarticular Injection in Total Knee Arthroplasty Patients With a History of Chronic Opioid Use

BACKGROUNDnPostoperative pain after total knee arthroplasty (TKA) poses a major challenge. It delays mobilization, increases opioid consumption and side effects, and lengthens hospitalization. This challenge multiplies when treating an opioid-dependent population. We examined whether a novel suspended release local anesthetic, liposomal bupivacaine (LB) would improve pain control and decrease opioid consumption after TKA compared to a standard periarticular injection in opioid-dependent patients.nnnMETHODSnThirty-eight patients undergoing TKA were randomly assigned to receive either a periarticular injection (PAI) with LB (nxa0= 20) or with a standard PAI (including a combination of ropivacaine, clonidine, Toradol, Epinepherine, and saline; nxa0= 18) as part of a multimodal pain management approach. All periarticular injections were done by a single surgeon. Perioperative treatment was similar between groups. Postoperative information regarding pain level was evaluated by a pain visual analog scale score. Postoperative opioid consumption was recorded.nnnRESULTSnAfter controlling baseline narcotic usage before surgery, no differences were found between groups in daily postoperative narcotic usage (Pxa0= .113), average daily pain score (Pxa0= .332), or maximum daily pain score (Pxa0= .881). However, when examining pain levels separately for each day, pain visual analog scale scores were reported higher in post operative day 1 in the LB group (Pxa0= .033).nnnCONCLUSIONSnLB was not found to be superior to standard PAI in opioid-dependent patients undergoing TKA. This patient population continues to present a challenge even with modern multimodal pain protocols.

Preemptive Analgesia in Hip Arthroscopy: A Randomized Controlled Trial of Preemptive Periacetabular or Intra-articular Bupivacaine in Addition to Postoperative Intra-articular Bupivacaine

PURPOSEnTo evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy.nnnMETHODSnForty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20xa0mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20xa0mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20xa0mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2xa0weeks after surgery.nnnRESULTSnTwenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30xa0minutes postoperatively and 18xa0hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 ± 1.49 vs 2.11 ± 2.29; Pxa0<xa0.045 and 2.62 ± 2.2 vs 4.79 ± 2.6; P < .009). There were no differences between the groups with regard to analgesic consumption.nnnCONCLUSIONSnPeriacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30xa0minutes and 18xa0hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected.nnnLEVEL OF EVIDENCEnLevel I, randomized controlled trial.

Neurolysis for the treatment of sciatic nerve palsy associated with total hip arthroplasty

Sciatic nerve palsy following total hip arthroplasty (THA) is a relatively rare yet potentially devastating complication. The purpose of this case series was to report the results of patients with a sciatic nerve palsy who presented between 2000 and 2010, following primary and revision THA and were treated with neurolysis. A retrospective review was made of 12 patients (eight women and four men), with sciatic nerve palsy following THA. The mean age of the patients was 62.7 years (50 to 72; standard deviation 6.9). They underwent interfascicular neurolysis for sciatic nerve palsy, after failing a trial of non-operative treatment for a minimum of six months. Following surgery, a statistically and clinically significant improvement in motor function was seen in all patients. The mean peroneal nerve score function improved from 0.42 (0 to 3) to 3 (1 to 5) (p < 0.001). The mean tibial nerve motor function score improved from 1.75 (1 to 4) to 3.92 (3 to 5) (p = 0.02).The mean improvement in sensory function was a clinically negligible 1 out of 5 in all patients. In total, 11 patients reported improvement in their pain following surgery. We conclude that neurolysis of the sciatic nerve has a favourable prognosis in patients with a sciatic nerve palsy following THA. Our findings suggest that surgery should not be delayed for > 12 months following injury.

Anchor suture fixation of distal pole fractures of patella: twenty seven cases and comparison to partial patellectomy

PurposePartial patellectomy (PP) and reattachment of the patellar ligament with transosseous suturing is the mainstay of surgical treatment for distal pole patellar fractures. An anchor suturing (AS) technique has recently been reported as an alternative to PP in such fractures and allows for bone-to-bone interface and possibly superior fracture healing than bone-to-tendon interface with PP. We present our experience with AS and compare it to PP.MethodsBetween 2006 and 2011, 60 patients with distal pole patellar fracture underwent either AS (nu2009=u200927) or PP (nu2009=u200933). We retrospectively gathered their demographic data and information on fracture type, fixation technique, operation time, postoperative complications and knee range of motion. A telephone survey was performed to grade functional outcomes with standard questionnaires (the SF-12 for quality of life, the Kujala score for patellofemoral function and a visual analog scale [VAS] pain score).ResultsAS was equivalent to PP in terms of residual pain and functional outcomes (VAS: 2.45 vs. 2.26, pu2009=u20090.83 and Kujala score: 74.3 vs. 69, pu2009=u20090.351, respectively) as well as for knee range of motion. Complications included three cases of infection in each group, two cases of early hardware failure and one case of non-union in the AS group. Operation time was significantly shorter for AS compared to PP (68.5 vs. 79.1xa0min, pu2009=u20090.03).ConclusionsAS is non-inferior to PP for function and pain after distal pole patellar fractures and is superior to PP with regard to operative time. Common complications of this technique are hardware failure and infections.Level of evidenceTherapeutic Level III

The radiological evaluation of the hip joint after prosthetic arthroplasty of the proximal femur in patients with a tumour using a bipolar femoral head

Excision of the proximal femur for tumour with prosthetic reconstruction using a bipolar femoral head places a considerable load on the unreplaced acetabulum. We retrospectively reviewed the changes which occur around the affected hip joint by evaluating the post-operative radiographs of 65 consecutive patients who underwent proximal prosthetic arthroplasty of the femur, and in whom an acetabular component had not been used. There were 37 men and 28 women with a mean age of 57.3 years (17 to 93). Radiological assessment included the extent of degenerative change in the acetabulum, heterotopic ossification, and protrusio acetabuli. The mean follow-up was 9.1 years (2 to 11.8). Degenerative changes in the acetabulum were seen in three patients (4.6%), Brooker grade 1 or 2 heterotopic ossification in 17 (26%) and protrusion of the prosthetic head in nine (13.8%). A total of eight patients (12.3%) needed a revision. Five were revised to the same type of prosthesis and three (4.6%) were converted to a total hip arthroplasty. We conclude that radiological evidence of degenerative change, heterotopic ossification and protrusion occur in a few patients who undergo prosthetic arthroplasty of the proximal femur for tumour. The limited extent of these changes and the lack of associated symptoms do not justify the routine arthroplasty of the acetabulum in these patients.

Single minimal incision fasciotomy for the treatment of chronic exertional compartment syndrome: outcomes and complications.

IntroductionChronic exertional compartment syndrome (CECS) is a common injury in young athletes, causing pain in the involved leg compartment during strenuous exercise. The gold standard treatment is fasciotomy, but most of the reports on its effectiveness include relatively small cohorts and relatively short follow-up periods. This study reports the long-term results of a large cohort of young athletes who underwent single-incision fasciotomy for CECS.Materials and methodsThis a retrospective case-series study. All patients treated by fasciotomies performed for CECS between 2007 and 2011, in a tertiary medical institution. CECS was diagnosed following history taking and clinical evaluation, and confirmed by compartment pressure measurements. Ninety-five legs that underwent single-incision subcutaneous fasciotomy were included. Data on the numerical analog scale (NAS), Tegner activity score, and quality-of-life (QOL) as measured via the short form-12 (SF-12) were retrieved from all patients preoperatively and at the end of follow-up.ResultsThe average time to diagnosis was 22xa0months and the mean follow-up was 50.1xa0months. Sixty-three legs underwent anterior compartment fasciotomy (an additional 30 legs also underwent lateral compartment release), and two legs underwent lateral and peroneal compartment releases. The average change in Tegner score was an improvement of 14.6 points. Similarly, the patients reported a significant improvement in the SF-12 and NAS scores. Satisfaction rates were high (average 75.5xa0%). The main complications were wound infection (2 patients) and nerve injuries (4 patients). Eight patients had recurrence.ConclusionSingle-incision fasciotomy leads to long-term improvement in the activity level and QOL of patients with CECS.

The medial border of the tibial tuberosity as an auxiliary tool for tibial component rotational alignment during total knee arthroplasty (TKA)

PurposeThe objective of this study was to quantify the amount of ensuing internal rotation of the tibial component when positioned along the medial border of the tibial tubercle, thus establishing a reproducible intraoperative reference for tibial component rotational alignment during total knee arthroplasty (TKA).MethodsThe angle formed from the tibial geometric centre to the intersection of both lines from the middle of the tibial tuberosity and its medial border was measured in 50 patients. The geometric centre was determined on an axial CT slice at 10xa0mm below the lateral tibial plateau and transposed to a slice at the level of the most prominent part of the tibial tuberosity. Similar measurements were taken in 25 patients after TKA, in order to simulate the intraoperative appearance of the tibia after making its proximal resection.ResultsThis angle was found to be similar (n.s.) in normal and post-TKA tibiae [median 20.4° (range 15°–24°) vs. 20.7° (range 16°–25°), respectively]. In 89.3xa0% of the patients, the angle ranged from 17° to 24°. No statistical difference (p n.s.) was found between women and men in both normal [median −20.7° (range 16°–25°) vs. 19.9° (range 15°–24°)] and post-TKA tibiae [median 21.4° (range 19°–24°) vs. 20° (range 16°–25°)].ConclusionThis study found that in 90xa0% of the patients, the medial border of the tibial tuberosity is internally rotated 17°–24° in relation to the line connecting the middle of the tuberosity to the tibial geometric centre. Since this anatomical landmark may be more easily identifiable intraoperatively than the commonly used “medial 1/3”, it can provide a better quantitative reference point and help surgeons achieve a more accurate tibial implant rotational position.Level of evidenceCohort and case control studies, Level III.

Rotator interval closure has no additional effect on shoulder stability compared to Bankart repair alone

PurposeArthroscopic Bankart repair (ABR) provides satisfactory results for recurrent anterior shoulder instability, but the high recurrence rate post-ABR remain a concern. One of the adjunct procedures proposed to improve ABR results is arthroscopic rotator interval closure (ARIC). This study prospectively evaluated the outcomes of ABRs alone compared to combined ABRu2009+u2009ARIC and identified risk factors related to failure of each procedure.MethodsThirty-nine consecutive patients (mean age 23.1 (18.3–37.5)xa0years; 37 males) underwent arthroscopic stabilization for recurrent anterior traumatic shoulder instability. Twenty patients underwent ABR alone and 19 underwent ABRu2009+u2009ARIC. Remplissage was added when glenoid engagement was observed during surgery. All patients were prospectively followed, and their postoperative courses were reviewed and functionally assessed at the last visit.ResultsThe re-dislocation rate was higher in the ABRu2009+u2009ARIC group compared to the ABR only group at a mean follow-up of 4.2 (2–5.6)xa0years (3 vs. 0, Pu2009=u20090.06). More subluxations were found in the ABR only group (2 vs. 1, respectively; Pu2009=u20090.58). The final limitation of range of motion (ROM) compared with the preoperative ROM was similar in both groups. Remplissage procedures were performed more often in the ABR only group [12 (60%) vs. 4 (21%), Pu2009=u20090.013].ConclusionsARIC performed as an adjunct to ABR showed no superiority in attaining value-added stability compared to ABR alone. Adding a remplissage procedure may achieve better stability.Level of evidenceLevel 2.

Inhibition of nucleotide pyrophosphatase/phosphodiesterase 1: implications for developing a calcium pyrophosphate deposition disease modifying drug

ObjectivesnCalcium pyrophosphate deposition (CPPD) is associated with osteoarthritis and is the cause of a common inflammatory articular disease. Ecto-nucleotide pyrophosphatase/phosphodiesterase 1 (eNPP1) is the major ecto-pyrophosphatase in chondrocytes and cartilage-derived matrix vesicles (MVs). Thus, eNPP1 is a principle contributor to extracellular pyrophosphate levels and a potential target for interventions aimed at preventing CPPD. Recently, we synthesized and described a novel eNPP1-specific inhibitor, SK4A, and we set out to evaluate whether this inhibitor attenuates nucleotide pyrophosphatase activity in human OA cartilage.nnnMethodsnCartilage tissue, chondrocytes and cartilage-derived MVs were obtained from donors with OA undergoing arthroplasty. The effect of SK4A on cell viability was assayed by the XTT method. eNPP1 expression was evaluated by western blot. Nucleotide pyrophosphatase activity was measured by a colorimetric assay and by HPLC analysis of adenosine triphosphate (ATP) levels. ATP-induced calcium deposition in cultured chondrocytes was visualized and quantified with Alizarin red S staining.nnnResultsnOA chondrocytes expressed eNPP1 in early passages, but this expression was subsequently lost upon further passaging. Similarly, significant nucleotide pyrophosphatase activity was only detected in early-passage chondrocytes. The eNPP1 inhibitor, SK4A, was not toxic to chondrocytes and stable in culture medium and human plasma. SK4A effectively inhibited nucleotide pyrophosphatase activity in whole cartilage tissue, in chondrocytes and in cartilage-derived MVs and reduced ATP-induced CPPD.nnnConclusionnNucleotide analogues such as SK4A may be developed as potent and specific inhibitors of eNPP1 for the purpose of lowering extracellular pyrophosphate levels in human cartilage with the aim of preventing and treating CPPD disease.

Surgical approach for open reduction and internal fixation of clavicle fractures: a comparison of vertical and horizontal incisions

PurposeThis study was designed to compare the results of clavicle fracture open reduction internal fixation (ORIF) with standard horizontal incision versus vertical incision.MethodsORIF surgery performed between October 2012 and August 2016 was included. The surgical approach was chosen according to surgeon preference as vertical or horizontal. Functional outcomes, fracture union, complications, scar appearance, skin irritation, and denervation around the scar were assessed at a minimum follow-up of three months.ResultsThirty-eight patients, age 39u2009±u200912xa0years, were operatedxa0upon, 22 through vertical incisions and 16 through horizontal incisions. There were no significant group differences in functional scores, fracture union, or complications. Two patients in the vertical incision group had a post-operative haematoma. The scar length was significantly shorter when a vertical incision was used (6.75u2009±u20091.25xa0cm vs 8.9u2009±u20092.3xa0cm, Pu2009=u20090.001). The typical distribution of hypoesthetic skin area distal and lateral to the scar represented iatrogenic damage to the supraclavicular nerves and was found in 66% of patients. The mean hypoesthetic surface area was smaller in the vertical incision group (38u2009±u200929xa0cm2 vs 48u2009±u200928xa0cm2, Pu2009=u2009non-significant).ConclusionVertical incision results in shorter scars but may be associated with increased incidence of haematomas. Meticulous closure of the subcutaneous tissue is recommended.