Robert G. Dekker

Single-Dose Adductor Canal Block With Local Infiltrative Analgesia Compared With Local Infiltrate Analgesia After Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

Background and Objectives A single-dose adductor canal block can provide postoperative analgesia for patients undergoing total knee arthroplasty (TKA). The purpose of this study was to assess postoperative opioid consumption after ultrasound-guided single-injection bupivacaine compared with saline adductor canal block for patients undergoing TKA. Methods After institutional review board approval, written informed consent was obtained from patients (>18 years old) undergoing elective TKA. Subjects were randomized into 2 groups as follows: adductor canal blockade with 10 mL of bupivacaine 0.25% with epinephrine 1:300,000 or 10 mL of normal saline. All patients received a periarticular infiltration mixture intraoperatively with scheduled and patient requested oral and IV analgesics postoperatively for breakthrough pain. Personnel blinded to group allocation recorded pain scores and opioid consumption every 6 hours. Pain burden, area under the numeric rating score for pain, was calculated for 36 hours. The primary outcome was postoperative IV-IM morphine (mg morEq) consumption at 36 hours after surgery. Results Forty (28 women-12 men) subjects were studied. Postoperative opioid consumption was reduced in the bupivacaine 48 (39 to 61) mg morEq compared with saline 60 (49 to 85) mg morEq, difference −12 (−33 to −2) mg morEq (P = 0.03). Pain burden at rest was decreased in the bupivacaine 71 (37 to 120) score · hours compared with saline 131 (92 to 161) score · hours, difference −60 (−93 to −14) score · hours (P = 0.009). Conclusions Adductor canal blockade with bupivacaine 0.25% with epinephrine 1:300,000 effectively reduces pain and opioid requirement in the postoperative period after TKA. Adductor canal blockade is an effective pain management adjunct for patients undergoing TKA.

Acute Achilles Tendon Ruptures: An Update on Treatment

Acute rupture of the Achilles tendon is common and seen most frequently in people who participate in recreational athletics into their thirties and forties. Although goals of treatment have not changed in the past 15 years, recent studies of nonsurgical management, specifically functional bracing with early range of motion, demonstrate rerupture rates similar to those of tendon repair and result in fewer wound and soft-tissue complications. Satisfactory outcomes may be obtained with nonsurgical or surgical treatment. Newer surgical techniques, including limited open and percutaneous repair, show rerupture rates similar to those of open repair but lower overall complication rates. Early research demonstrates no improvement in functional outcomes or tendon properties with the use of platelet-rich plasma, but promising results with the use of bone marrow-derived stem cells have been seen in animal models. Further investigation is necessary to warrant routine use of biologic adjuncts in the management of acute Achilles tendon ruptures.

Total ankle arthroplasty versus ankle arthrodesis—a comparison of outcomes over the last decade

BackgroundThe surgical treatment of end-stage tibiotalar arthritis continues to be a controversial topic. Advances in surgical technique and implant design have lead to improved outcomes after both ankle arthrodesis (AA) and total ankle arthroplasty (TAA), yet a clear consensus regarding the most ideal form of treatment is lacking. In this study, the outcomes and complications following AA and TAA are compared in order to improve our understanding and decision-making for care and treatment of symptomatic tibiotalar arthritis.MethodsStudies reporting on outcomes and complications following TAA or AA were obtained for review from the PubMed database between January 2006 and July 2016. Results from studies reporting on a minimum of 200 total ankle arthroplasties or a minimum of 80 ankle arthrodesis procedures were reviewed and pooled for analysis. All studies directly comparing outcomes and complications between TAA and AA were also included for review. Only studies including modern third-generation TAA implants approved for use in the USA (HINTEGRA, STAR, Salto, INBONE) were included.ResultsA total of six studies reporting on outcomes following TAA and five reporting on outcomes following AA met inclusion criteria and were included for pooled data analysis. The adjusted overall complication rate was higher for AA (26.9%) compared to TAA (19.7%), with similar findings in the non-revision reoperation rate (12.9% for AA compared to 9.5% for TAA). The adjusted revision reoperation rate for TAA (7.9%) was higher than AA (5.4%). Analysis of results from ten studies directly comparing TAA to AA suggests a more symmetric gait and less impairment on uneven surfaces after TAA.ConclusionsPooled data analysis demonstrated a higher overall complication rate after AA, but a higher reoperation rate for revision after TAA. Based on the existing literature, the decision to proceed with TAA or AA for end-stage ankle arthritis should be made on an individual patient basis.

Safety and Outcomes of Inpatient Compared with Outpatient Surgical Procedures for Ankle Fractures.

BACKGROUND As the cost of health-care delivery rises in the era of bundled payments for care, there is an impetus toward minimizing hospitalization. Evidence to support the safety of open reduction and internal fixation (ORIF) of ankle fractures in the outpatient setting is largely anecdotal. METHODS Patients who underwent ORIF from 2005 to 2013 were identified via postoperative diagnoses of ankle fracture and Current Procedural Terminology codes; patients with open fractures and patients who were emergency cases were excluded. Patients undergoing inpatient and outpatient surgical procedures were propensity score-matched to reduce differences in the baseline characteristics. Primary tracked outcomes included medical and surgical complications, readmission, and reoperation within 30 days of the procedure. Binary logistic regression models were created that determined the risk-adjusted relationship between admission status and primary outcomes. RESULTS Outpatient surgical procedures were associated with lower rates of urinary tract infection (0.4% compared with 0.9%; p = 0.041), pneumonia (0.0% compared with 0.5%; p = 0.002), venous thromboembolic events (0.3% compared with 0.8%; p = 0.049), and bleeding requiring transfusion (0.1% compared with 0.6%; p = 0.012). Outpatient status was independently associated with reduced 30-day medical morbidity (odds ratio, 0.344 [95% confidence interval, 0.201 to 0.589]). No significant differences were uncovered with respect to surgical complications (p = 0.076), unplanned reoperations (p = 0.301), and unplanned readmissions (p = 0.358). CONCLUSIONS In patients with closed fractures and minimal comorbidities, outpatient ORIF was associated with reduced risk of select 30-day medical morbidity and no difference in surgical morbidity, reoperations, and readmissions relative to inpatient. Factors unaccounted for when creating matched cohorts may impact our results. Our findings lend reassurance to surgeons who defer admission for low-risk patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outpatient Management of Ankle Fractures

Interest in outpatient orthopedic surgery has been fueled by provider desire to control costs and development of rapid recovery protocols. Open reduction and internal fixation (ORIF) is a commonly elected treatment strategy for ankle fracture that may be performed in an outpatient setting. Lessons on cost-savings of the outpatient model in orthopedics can be learned in total joint replacement and spine surgery. Moreover, in properly selected patients, outpatient ORIF has been shown to be comparably safe. Reasons for admission of the surgically managed patient with ankle fractures, including concern for surgical delay and additional social factors, warrant further investigation.

Chronic Syndesmotic Injuries and Reconstruction

Chronic instability of the distal tibiofibular syndesmosis is associated with poor functional outcomes and the development of arthritis. Stabilization of the distal tibiofibular joint after a neglected or recurrent diastasis can be accomplished using a variety of surgical procedures; however, no 1 technique has shown clear superiority. Arthrodesis is considered the most reproducible means of restoring stability at the distal tibiofibular joint; however, the limitation of motion can be associated with ankle pain and may exacerbate symptoms from early ankle degenerative disease. This article presents an algorithmic approach using a double limb allograft reconstruction for symptomatic patients with persistent radiographic widening and either subtle syndesmotic instability or significant disruption and lateral talar shift due to attenuated or disrupted syndesmotic ligaments. The technique primarily reconstructs the interosseous ligament and does not attempt to individually recreate each ligament of the syndesmosis to preserve physiological fibula rotation and translation. Early outcomes have been excellent. Level of Evidence: Diagnostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Simulated Weight Bearing and Articular Injury From Transarticular Screws In A Lisfranc Injury Model

Category: Midfoot/Forefoot, Trauma Introduction/Purpose: Successful treatment of Lisfranc injuries, relies upon anatomic reduction [1-3] and rigid fixation until bony or ligamentous healing has occurred and inherent stability has been restored. Historically, transarticular screw fixation has been the most common method of fixation, but optimal treatment remains controversial. Articular injury from transarticular screw fixation may lead to arthritis of the Lisfranc joints and future morbidity. To our knowledge only two studies have evaluated articular injury from transarticular screws [6,7]. Neither of these studies, and no other study to our knowledge has investigated relative increase in articular damage after simulated weight bearing. The aims of this study were: (1) create a ligamentous Lisfranc injury model and (2) compare relative increase in articular injury pre- and post-simulated weight bearing from screw toggle. Methods: 10 cadaver specimens underwent transarcticular screw fixation with 3.5 mm cortical screws in a ligamentous Lisfranc injury model. Digital photographs of the articular surfaces of the first and second tarsometatarsal joints were taken before and after cycling. Simulated weight bearing was performed with each specimen cycled 1,000 cycles at 222.4 N in a custom jig fixed in approximately 20 degrees of plantar flexion. After creation of the Lisfranc injury and prior to cycling with screw fixation, each specimen was cycled for 20 cycles to ensure we had created a reliable injury model. At each stage we assessed total relative rotation and diastasis between each of the bones of the Lisfranc complex. After simulated weight bearing hardware was removed and digital photographs were again taken. Articular injury was measured as a percentage of total articular surface pre- and post-cycling and was compared and statistical analysis performed. Results: Our model produced motion consistent with a ligamentous Lisfranc injury. Overall, the articular injury increased by 44.22% (p<0.001) after cyclic loading. With respect to each individual surface, the second metatarsal (M2) showed the greatest increase in articular injury (53.89%, p=0.0047) whereas the first metatarsal (M1) showed the least (34.71%, p=0.0083). The increases seen at the medial cuneiform (43.51%, p=0.0387) and the middle cuneiform (44.24%, p=0.0292) were intermediate between the values seen at M2 and M1 (Table 1). Conclusion: Our model produced motion consistent with a ligamentous Lisfranc injury. The articular injury from transarticular screw fixation showed a significant increase in articular injury with cyclic loading at each of the articular surfaces of interest and a 44% overall increase in articular damage with simulated weight bearing. This relative increase in articular injury has never previously been studied. This increase in articular injury from screw toggle with simulated weight bearing with use of trans- articular screw fixation is significant and may increase the risk of arthritis and future morbidity when using this fixation strategy.

A Biomechanical Comparison of a Limited Open and Standard Open Technique for Achilles Tendon Rupture Repair

Category: Basic Sciences/Biologics, Sports Introduction/Purpose: The drive to reduce soft tissue complications after Achilles tendon repair has led to increased interest in less invasive techniques. The PARS Achilles Jig System is one option that has gained popularity as an alternative to open repair. For many surgeons, standard open repair consists of a Krackow locking-loop technique. We compared the load to failure of a limited open and open Krackow technique for repair of Achilles tendon ruptures. Methods: Nine pairs of human cadaver lower limbs were randomized to undergo either a Krackow locking loop repair with epitendinous weave or a PARS Achilles Jig System Repair. Specimen were loaded to failure on a servo-hydraulic material testing machine. From load- displacement curves, initial linear stiffness, load to failure, and work to failure were calculated. Results: The average load to failure for Krackow repair (353.8 ± 88.8 N) and PARS repair (313.3 ± 99.9 N) was not statistically different (p = .38). The average work to failure for open repair (6.4 ± 2.3 J) and PARS repair (6.3 ± 3.5 J) was also not statistically different (p = .904). Mean initial linear stiffness of the Krackow repair (17.8 ± 5.4 N/mm) was significantly greater than the PARS repair (11.8 ± 2.5 N/mm) (p = .011). The predominant location of failure for Krackow repair was at the suture itself. In contrast, the PARS repair predominantly failed at the suture-tendon interface. Conclusion: The results suggest no difference between the Krackow and PARS repairs in terms of ultimate strength or work to failure. The Krackow repair demonstrated a higher initial linear stiffness than the PARS, which may imply a greater ability to withstand gap formation. With less devitalization to surrounding soft tissue and equal repair strength, the PARS system should be considered a favourable option for repair of ruptured Achilles tendons.

A Biomechanical Comparison of Limited Open Versus Krackow Repair for Achilles Tendon Rupture

Background: Soft tissue complications after Achilles tendon repair has led to increased interest in less invasive techniques. Various limited open techniques have gained popularity as an alternative to open operative repair. The purpose of this study was to biomechanically compare an open Krackow and limited open repair for Achilles tendon rupture. We hypothesized that there would be no statistical difference in load to failure, work to failure, and initial linear stiffness. Methods: A simulated Achilles tendon rupture was created 4 cm proximal to its insertion in 18 fresh-frozen cadaveric below-knee lower limbs. Specimens were randomized to open or limited open PARS Achilles Jig System repair. Repairs were loaded to failure at a rate of 25.4 mm/s to reflect loading during normal ankle range of motion. Load to failure, work to failure, and initial linear stiffness were compared between the 2 repair types. Results: The average load to failure (353.8 ± 88.8 N vs 313.3 ± 99.9 N; P = .38) and work to failure (6.4 ± 2.3 J vs 6.3 ± 3.5 J; P = .904) were not statistically different for Krackow and PARS repair, respectively. Mean initial linear stiffness of the Krackow repair (17.8 ± 5.4 N/mm) was significantly greater than PARS repair (11.8 ± 2.5 N/mm) (P = .011). Conclusion: No significant difference in repair strength was seen, but higher initial linear stiffness for Krackow repair suggests superior resistance to gap formation, which may occur during postoperative rehabilitation. With equal repair strength, but less soft tissue devitalization, the PARS may be a favorable option for patients with risk factors for soft tissue complications.

Effect of First Metatarsophalangeal Joint Arthrodesis on PROMIS Functional Outcomes and Radiographic Alignment for Hallux Rigidus

Category: Midfoot/Forefoot Introduction/Purpose: Improvement in first ray alignment after arthrodesis of the arthritic first metatarsophalangeal (MTP) joint has been shown, yet few studies have attempted to correlate radiographic alignment with functional outcomes. The purpose of this study was to determine if 1st MTP joint deformity due to hallux rigidus correlates with patient reported pain and function, and whether there is a correlation between outcomes and radiographic measurements made before and after surgery. We also sought to determine how 1st MTP joint arthrodesis affects patient reported pain and function in a series of patients with hallux rigidus using a validated outcome measure. Methods: We conducted a retrospective study on patients treated with 1st MTP joint arthrodesis for diagnosis of hallux rigidus from 2012 to 2014 using a single surgical technique. The hallux-valgus angle (HVA), intermetatarsal angle (1-2 IMA) and lateral talar first metatarsal angle (L1TMTA) were measured independently by the senior author and an Orthopaedic Surgery fellow on pre- and post-operative radiographs. Inter-observer and intra-observer coefficients of repeatability were calculated. Pre- and post- operative physical function and pain scores were generated using the Patient Reported Outcome Measurement Information System (PROMIS). Paired t-test was used to detect differences. Bivariate analysis was used to assess radiographic measurement and PROMIS score correlation. Results: 30 subjects met inclusion criteria for radiographic analysis. Mean pre- and post-operative IMA, HVA and LT1MTA are shown in Table I. 23 subjects had pre-operative PROMIS data. Mean pre-operative pain and function were 72.7 and 32.0. Only pre-operative HVA significantly correlated with pre-operative physical function scores, with Pearson correlation value of 0.507 (p = 0.014). 7 subjects had pre- and post-fusion PROMIS data with average follow up 173 days post-fusion (minimum 130, maximum 196). Mean change in pain and function were -9.14 (p = 0.094) and 6.57 (p = 0.31), respectively. Only change in patient reported pain significantly correlated with change in HVA, with a Pearson correlation value of -0.76 (p = 0.05). Interclass correlation coeffecients for interoperator reliability ranged from 0.835 to 0.998. Conclusion: 1st MTP joint arthrodesis significantly improved radiographic IMA, HVA and LT1MTA for patients with hallux rigidus. In a small series of patients, arthrodesis improved patient reported pain and function, but this was not significant. Only pre-operative HVA correlated with pre-operative physical function, while only change in HVA correlated with change in patient reported pain after arthrodesis. Special attention should be paid to the HVA for the patient undergoing 1st MTP arthrodesis for hallux rigidus.