Orthopaedic surgeons prescribe more opioids than any other surgical speciality. Opioids remain the analgesic of choice following arthroscopic knee and shoulder surgery. There is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients’ pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. The objective of the current randomized controlled trial (RCT) was to evaluate the efficacy of a multi-modal, opioid-sparing approach to postoperative pain management in patients undergoing arthroscopic shoulder and knee surgery. The NO PAin trial is a pragmatic, definitive RCT (NCT04566250) enrolling 200 adult patients undergoing outpatient shoulder or knee arthroscopy. Patients are randomly assigned in a 1:1 ratio to an opioid-sparing group or standard of care. The opioid-sparing group receives a three-pronged prescription package consisting of 1) a non-opioid prescription: naproxen, acetaminophen and pantoprazole, 2) a limited opioid “rescue prescription” of hydromorphone, and 3) a patient education infographic. The control group is the current standard of care as per the treating surgeon, which consists of an opioid analgesic. The primary outcome of interest is oral morphine equivalent (OME) consumption up to 6 weeks postoperatively. The secondary outcomes are postoperative pain scores, patient satisfaction, quantity of OMEs prescribed and number of opioid refills. Patients are followed at both 2 and 6 weeks postoperatively. Data analysts and outcome assessors are blinded to the treatment groups. As of December 1, 2021 we have enrolled 166 patients, reaching 83% of target enrolment. Based on the current recruitment rate, we anticipate that enrolment will be completed by the end of January 2022 with final follow-up and study close out completed by March of 2022. The final results will be released at the Canadian Orthopaedic Association Meeting in June 2022 and be presented as follows. The mean difference in OME consumption was XX (95%CI: YY-YY, p=X). The mean difference in OMEs prescribed was XX (95%CI: YY-YY, p=X). The mean difference in Visual Analogue Pain Scores (VAS) and patient satisfaction are XX (95%CI: YY-YY, p=X). The absolute difference in opioid refills was XX (95%CI: YY-YY, p=X). The results of the current study will demonstrate whether an opioid sparing approach to postoperative outpatient pain management is effective at reducing opioid consumption while adequately addressing postoperative pain in patients undergoing outpatient shoulder and knee arthroscopy. This study is novel in the field of
The purpose of this study was to compare the outcomes of
Aim: To determine the effectiveness of
Tears of the posterior horn of the menisci often call for
Purpose: Disposable medical devices have several advantages and are widely used. But since the financial burden of disposable devices is however significant for the hospital budget, it would be interesting to reassess multiple use devices in terms of efficacy and safety. The purpose of this study was to determine the safety aspects involved and to assess wear observed in new versions of autoclavable shavers and drill bits used in
Purpose : The purpose of this study is to assess the effectiveness of the arthroscopic method in the stiffness of elbow after osteoarthritis or posttraumatic arthritis. Materials and methods : In the time period January 1999 to December 2001, 11 patients with primary osteoarthritis and posttraumatic arthritis of the elbow were treated in our clinic with the arthroscopic method. All patients had stiffness and pain. Nine of them were men and two women with a mean age of 46 years (range 28–56 years). Average preoperative flexion was to 1150 (range 90 – 1400), and average extension loss was −250 (range 15 – 350). Mean follow-up was 30,3 months. Results : The range of motion showed a progressive increase until 1 year after surgery. However, after 1 year, the range of motion showed little additional increase, especially in laborers. The range of motion acquired during surgery usually was the same range that patients achieved during the rehabilitation period. Average postoperative flexion was to 1380 (range 120 – 1430) and average extension was to 50 (range 0 – 120). The range of motion showed more improvement in patients whose duration of symptoms was less than 1 year than in those whose duration of symptoms was longer than 1 year. All patients had a significant decrease in pain and 5 of them complete relief of pain. Conclusions : The
Since its creation, labral repair has become the preferred method among surgeons for the arthroscopic treatment of acetabular labral tears resulting in pain and dysfunction for patients. Labral reconstruction is performed mainly in revision hip arthroscopy but can be used in the primary setting when the labrum cannot be repaired or is calcified. The purpose of this study was to compare the survival between primary labral repair and labral reconstruction with survival defined as no further surgery (revision or total hip replacement). Patients who underwent labral repair or reconstruction between January 2005 and December 2018 in the primary setting were included in the study. Patients were included if they had primary hip arthroscopy with the senior author for femoroacetabular impingement (FAI), involving either labral reconstruction or labral repair, and were within the ages of 18 and 65 at the time of surgery. Exclusion criteria included confounding injuries (Leggs Calves Perthes, avascular necrosis, femoral head fracture, etc.), history of unilateral or bilateral hip surgeries, or Tönnis grades of 2 or 3 at the time of surgery. Labral repairs were performed when adequate tissue was available for repair and labral reconstruction was performed when tissue was absent, ossified or torn beyond repair. A total of 501 labral repairs and 114 labral reconstructions performed in the primary setting were included in the study. Labral reconstruction patients were older (37±10) compared to labral repair (34±11).(p=0.021). Second surgeries were required in 19/114 (17%) of labral reconstruction and 40/501(8%) [odds ratio: 2.3; 95% CI 1.3 to 4.2] (p=0.008). Revision hip arthroscopy were required in 6/114(5%) labral reconstructions and 33/501(6.5%) labral repair (p=0.496). Total hip replacement was required in 13/114 labral reconstructions and 7/501 labral repairs [odds ratio:9.1 95%CI 3.5 to 23] (p=< 0.01). The mean survival for the labral repair group was 10.2 years (95%CI:10 to 10.5) and 11.9 years (98%CI:10.9 to 12.8) in the labral reconstruction group. Conversion to total hip was required more often following primary labral reconstruction. Revision hip arthroscopy rates were similar between groups as was the mean survival, with both over 10 years. Similar survival was seen in labral repair and reconstruction when strict patient selection criteria are followed.
Aims: The re-dislocation rates in adults (<
30 years) in the initial 12 months after FAT (first,anterior,traumatic) shoulder dislocations treated non-operatively vary from 25% to 95%. Some surgeons advocate early
Aim: The re-dislocation rates in adults (<
30 years) in the initial 12 months after first, anterior, traumatic (FAT) shoulder dislocations treated non-operatively vary from 25% to 95%. The purpose of this study was to establish if
Malnutrition is an important consideration during the perioperative period and albumin is the most common laboratory surrogate for nutritional status. The purpose of this study is to identify if preoperative serum albumin measurements are predictive of infection following arthroscopic procedures. Patients undergoing knee, shoulder or hip arthroscopy between 2006–2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patients with an arthroscopic current procedural terminology code and a preoperative serum albumin measurement were included. Patients with a history of prior infection, including a non-clean wound class, pre-existing wound infection or systemic sepsis were excluded. Independent t-tests where used to compare albumin values in patients with and without the occurrence of a postoperative infection. Pre-operative albumin levels were subsequently evaluated as predictors of infection with logistic regression models. There were 31,906 patients who met the inclusion criteria. The average age was 55.7 years (standard deviation (SD) 14.62) and average BMI was 31.7 (SD 7.21). The most prevalent comorbidities were hypertension (49.2%), diabetes (18.4%) and smoking history (16.9%). The average preoperative albumin was 4.18 (SD 0.42). There were 45 cases of superficial infection (0.14%), 10 cases of wound dehiscence (0.03%), 17 cases of deep infection (0.05%), 27 cases of septic arthritis or other organ space infection (0.08%) and 95 cases of any infection (0.30%). The preoperative albumin levels for patients who developed septic arthritis (mean difference (MD) 0.20, 95% CI, 0.038, 0.35, P = 0.015) or any infection (MD 0.14, 95% CI 0.05, 0.22, P = 0.002) were significantly lower than the normal population. Additionally, disseminated cancer, Hispanic race, inpatient status and smoking history were significant independent risk factors for infection, while female sex and increasing albumin were protective towards developing any infection. Rates of all infections were found to increase exponentially with decreasing albumin. The relative risk of infection with an albumin of 2 was 3.46 (95% CI, 2.74–4.38) when compared to a normal albumin of 4. For each albumin increase of 0.69, the odds of developing any infection decreases by a factor of 0.52. This study suggests that preoperative serum albumin is an independent predictor of septic arthritis and all infection following elective arthroscopic procedures. Although the effect of albumin on infection is modest, malnutrition may represent a modifiable risk factor with regard to preventing infection following arthroscopy.
The primary treatment goal for patients with femoroacetabular impingement syndrome, a common hip condition in athletes, is to improve pain and function. In selected patients, in the short term following intervention,
Elite performance has tremendous physical demands and places elite athletes at an increased risk of sustaining a variety of orthopaedic injuries (1–4). Pain around the hip is common in high-level athletes representing up to 6% of all athletic injuries (5–7). Expedient diagnosis and effective treatment are paramount for their future sporting careers and to prevent subsequent joint degeneration. The purpose of this systematic review was to evaluate the outcome and the rate of return to play (RTP) following hip arthroscopy in elite athletes. A computer-based systematic search followed the PRISMA Guidelines (8) was performed using the 6 most comprehensive databases (CENTRAL, PUBMED, EMBASE, SCOPUS, EBSCO, Google Scholar and Web of Science) and included all published studies from inception until November 1st 2018. Weighted means were calculated for the rate of RTP and duration and for patient reported outcome measures (PROMs).Background
Methods
The technique of arthroscopic decompression of patellar tendonitis was first undertaken in 1990. We report the 10 year experience of using this technique. Patients presenting with this condition were subjected to clinical, radiological and MRI assessment. The procedure was undertaken if the symptoms continued to be significant despite non-operative treatment. The procedure used a Dyonics shaver. The fat pad was elevated from the bare area of the patella to expose the non-articular inferior pole of the patella. The tendon fibres were then elevated from the anterior surface of the inferior pole, and the 5mm tip of the patella was excised taking particular care to ensure that the full AP thickness was removed. Seventy three knees underwent surgery with a minimum of one year follow up, in four cases a simultaneous bilateral procedure was performed and in 11 cases previous surgery had been performed elsewhere. The average age was 33 years, 64 of the cases were male. The average duration of symptoms was 20 months and all patients had undergone non-operative treatment prior to the index procedure for an average duration of 10 months. The average duration of follow up was 49 months. All patients experienced a significant improvement in the clinical grade of symptoms and function with 95% of the 62 primary cases resulting in a good or excellent result. The average time to return to work and driving was 2 weeks and to sport was 9 weeks. In the 11 revision cases, 9 (81%) were improved and 6 (55%) had a good result. The results of arthroscopic decompression for patellar tendonitis are superior to the other reported techniques. We conclude that excision of the inflammatory nodule and fat pad in this condition is unnecessary, other than to obtain visualisation of the inferior pole of the patella. The success of this procedure supports the suggestion that this condition is produced by a compression of the tendon and is best treated by decompression of the inferior patella pole.
Recently concerns have been raised as to the effect of intra-articular radio-frequency energy on axillary nerve function. In our unit 120 shrinkage procedures have been performed with 5 intra-operative contractions of deltoid and no axillary nerve palsy. In this study we aimed to identify and quantify any changes in axillary nerve function following capsular shrinkage. Needle electrodes were inserted into the deltoid muscle of 10 patients undergoing radio-frequency capsular shrinkage and 3 patients having diagnostic arthroscopy. Recordings of Compound Muscle Action Potentials (CMAPs) were made following pre-operative magnetic coil stimulation of the axillary nerve. The nerve was then monitored during operation. At the end of the procedure, a further recording of CMAP following axillary nerve stimulation was made to allow comparison with initial readings. We have shown:
Low amplitude stimulations of the axillary nerve in 6 of the 10 patients undergoing shrinkage. Increase in latency of the axillary nerve was noted in some patients including the controls. Increase in latency was independent of time spent performing shrinkage. We have concluded:-
Stimulation of the axillary nerve occurs frequently during capsular shrinkage. This axillary nerve stimulation cannot be causally related to the application of radio-frequency energy. Increased latency may occur due to cooling of the nerve by extravasated irrigation fluid. Nerve monitoring is recommended during the training of surgeons new to this technique. We would like to acknowledge the Magstim Company for their assistance with this project.
Arthroscopic soft tissue debridement of the AC Joint without excising the distal clavicle, is a bone sparing procedure that, to our knowledge, has never been reported in the literature. This paper is a retrospective review of patients with chronic recalcitrant AC joint injuries, who underwent arthroscopic soft tissue debridement of the AC joint.
The surgery involves a glenohumeral joint arthroscopy, subacromial bursoscopy and AC joint arthroscopy. Excision of the torn AC joint meniscus, AC joint synovectomy and soft tissue clearance were performed in all cases. Surgery was performed as a day-only procedure.
Five patients had previously undiagnosed SLAP tears.
Arthroscopic soft tissue debridement for recalcitrant AC joint injuries gave good results in 77% of cases. Arthroscopy of the glenohumeral joint in patients with presumed isolated AC joint disease is important as there is a significant proportion of patients who have associated significant superior labral tears. Soft tissue arthroscopic AC joint debridement allows quick post-operative rehabilitation, an early return to sport and work and avoids having to excise bone from the distal clavicle. Arthroscopic AC joint debridement is contraindicated in patients who have grade II or grade III AC joint instability.
This study presents the results of 60 consecutive hip arthroscopic procedures for the treatment of Acetabulo-Femoral Impingement. The procedures were performed by a single surgeon over a period of 36 months. The learning curve and the evolution of the current technique along with the clinical outcomes are discussed Additionally two new clinical signs of AFI are described, along with the correlation of radiological and arthroscopic findings. Sixty patients underwent hip arthroscopies. The procedures included labral debridement, labral repair, femoral and/or acetabular osteectomies. All patients underwent MRI examination and three-dimensional CT imaging to identify the impingement lesion. Follow up CT scanning was performed to assess the accuracy of the bony resection. Patients were reviewed at three months and subsequently at twelve monthly intervals. All patients participated in completing questionnaires. Post-operatively Modified Harris Hip score improved from 54 to 70, Non-Arthritic hip score improved from 58 to 75, SF12 score improved from 35 to 40. Three patients required a second procedure for further bony resection. One patient underwent a THR within 12 months. Two female patients suffered minor vaginal abrasions. Hip arthroscopy is a demanding procedure. Good clinical results are achieved only when the cause of impingement has been identified and treated.
Hip arthroscopy has gradually evolved over the past two decades. Recently hip arthroscopy has an increasing role in diagnosis and treatment for specific intra articular and extra articular hip injuries and especially for soft tissue injuries. February 2002 – May 2009
18 athletes 5 football players 8 basketball players 2 weight lifters 3 gymnasts Mean age: 32 y.o. (19–39 y.o.) Undiagnosed hip pain, Osteoarthritis, Labral pathology, Loose bodies, Osteochondral defects, Sepsis, Liga-mentum Teres, Trauma, Synovitis Symptoms: Deep dull ache pain during hip flexion and external or internal rotation. Decreased R.O.M. 12/18 Cam sign + (positive), 11/18 Pincher sign + (positive), 14/18 Impingement syndrome in adduction and in flexion. Instrumentation and Equipment: 30°, 70°, 4,5mm arthroscope, High flow rate mechanical pump, 15 gauge 6" cardiac needle, Convex full radius chondroplasty blades, Special electrocautery (Philippon), Distraction apparatus, Mechanical water pump unit, Image intensifier
Surgery: Standard orthopaedic traction table, Supine position, Hip is extended and abducted 25° Portals: Anterior, Anterolateral, Posterolateral Intraoperative Findings – Results Detachment of the labrum, 2/18 erosion of the articular cartilage of the acetabulum and drilling of the bare area, 12/18 Cam sign excision The athletes with symptoms of an internal hip pain and impingement signs after a clinical exam of their hip will get a benefit from an arthroscopic procedure for treating any existing cetabulo-femoral pathology, especially for the athletes with femoraloacetabular impingement syndrome (FAI).