Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures. We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs. This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB.
Interstitial supraspinatus tears can cause persistent subacromial impingement symptoms despite non operative treatment. Autologous tendon cell injection (ATI) is a non-surgical treatment for tendinopathies and tear. We report a randomised controlled study of ATI compared to corticosteroid injection (CS) as treatment for interstitial supraspinatus tears and tendinopathy. Inclusion criteria were patients with symptom duration > 6 months, MRI confirmed intrasubstance supraspinatus tear, and prior treatment with physiotherapy and ≥ one CS or PRP injection. Participants were randomised to receive ATI to the interstitial tear or corticosteroid injection to the subacromial bursa in a 2:1 ratio, under ultrasound guidance. Assessments of pain (VAS) and function (ASES) were performed at baseline, and 1, 3, 6 and 12 months post treatment. 30 participants (19 randomised to ATI) with a mean age of 50.5 years (10 females) and a mean duration of symptoms of 23.5 months. Baseline
Progressive collapsing foot deformity (PCFD) is a complex foot deformity with varying degrees of hindfoot valgus, forefoot abduction, forefoot varus, and collapse or hypermobility of the medial column. In its management, muscle and tendon balancing are important to address the deformity. Peroneus brevis is the primary evertor of the foot, and the strongest antagonist to the tibialis posterior. Moreover, peroneus longus is an important stabilizer of the medial column. To our knowledge, the role of peroneus brevis to peroneus longus tendon transfer in cases of PCFD has not been reported. This study evaluates patient reported outcomes including pain scores and any associated surgical complications for patients with PCFD undergoing isolated peroneus brevis to longus tendon transfer and gastrocnemius recession. Patients with symptomatic PCFD who had failed non-operative treatment, and underwent isolated soft tissue correction with peroneus brevis to longus tendon transfer and gastrocnemius recession were included. Procedures were performed by a single surgeon at a large University affiliated teaching hospital between January 1 2016 to March 31 2021. Patients younger than 18 years old, or undergoing surgical correction for PCFD which included osseous correction were excluded. Patient demographics, medical comorbidities, procedures performed, and pre and post-operative patient related outcomes were collected via medical chart review and using the appropriate questionnaires. Outcomes assessed included Visual Analogue Scale (VAS) for foot and ankle pain as well as sinus tarsi pain (0-10), patient reported outcomes on EQ-5D, and documented complications. Statistical analysis was utilized to report change in VAS and EQ-5D outcomes using a paired t-test. Statistical significance was noted with p<0.05. We analysed 43 feet in 39 adults who fulfilled the inclusion criteria. Mean age was 55.4 ± 14.5 years old. The patient reported outcome mean results and statistical analysis are shown in Table one below. Mean pre and post-operative foot and ankle
The relationship between pain catastrophizing and emotional disorders including anxiety and depression in patients with hip or knee osteoarthritis undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between catastrophizing, anxiety, depression and postoperative pain and functional outcomes following primary TJR. A prospective cohort study of preoperative TJR patients at one academic arthroplasty centre over a one-year period was conducted. Pain catastrophizing was assessed using the Pain Catastrophizing Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D) at preoperative assessment. Postoperative outcomes at one-year included patient perceived level of hip/knee pain using a visual analogue scale (VAS), subjective perception of function using the Oxford Hip/Knee Scores, and objective function using the Knee Society Score (KSS) and Harris Hip scores (HHS). Median regression was used to assess pattern of relationship between preoperative PCS clinically relevant catastrophizing (CRC), abnormal HADS-A, abnormal HADS-D and postoperative outcomes at one-year. Median difference and 95% confidence interval (CI) were reported. T-tests were performed to determine mean differences in postoperative outcomes among patients with PCS CRC, abnormal HADS-A, and abnormal HADS-D scores versus those with normal scores at preoperative assessment. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees). Both the PCS-rumination CRC sub-domain (median difference 1, 95% CI 0.31–1.69, p=0.005) and abnormal HADS-A (median difference 1, 95% CI 0.36–1.64, p=0.002) were identified as significant predictors of one-year
Introduction. Direct anterior approach (DAA) total hip arthroplasty (THA) has been reported to improve early outcomes as compared to posterior approach THA up to 6 weeks post-operatively. However, very few detailed results have been reported within the first 6 weeks. In this study we investigate the effect of surgical approach on THA outcome via weekly assessment. Methods. Patients undergoing THA for primary osteoarthritis were prospectively enrolled. Data was collected pre-operatively and post-operatively at weekly intervals for 6 weeks. Outcome scores and additional functional measures were compared using unpaired t-test, effect size, and Pearson correlation coefficients. Results. 111 patients (55 DAA and 56 posterior approach) were enrolled. There was no significant difference (p>0.05) in pre-surgical Patient Reported Outcome Measurement Information System (PROMIS) Pain interference and Physical Function scores,
Background. Traditional teaching recommends against arthroplasty in the index finger, due to concerns over failure with pinch stress, and prefers arthrodesis is for its stability. We aim to allay these fears and present the results of our series of index finger silastic PIPJ arthroplasties. Methods: Between 2007 & 2018 48 silastic index finger PIPJ arthroplasties were undertaken in 37 patients at our Hand Unit. All were performed under local anaesthetic ring block. Eleven patients underwent PIPJ arthroplasty in both Index fingers. Thirty-five women and two men made up the cohort with a mean age of 69 years. A retrospective analysis of all patients has been undertaken to determine the clinical results including patient satisfaction, grip and pinch strength and reoperation rates. Mean follow up was 5.1 years. Results. Six index fingers developed ulnar deviation greater than 10 degrees and there were five reoperations (10.2%). There was an excellent arc of movement of mean 44 degrees with high patient satisfaction and functional scores (mean
Introduction. Outpatient total joint arthroplasty (TJA) is emerging as a viable alternative to the historically accepted hospital based inpatient TJA in the United States. Several studies have focused on the financial advantages of outpatient TJA, however little research has discussed patient reported outcome measures (PROM) and the overall patient experience. This is a retrospective comparison of PROM data in patients undergoing outpatient vs. inpatient total hip arthroplasty (THA). Methods. An internal quality metric database analysis was performed on patients undergoing THA between 2/14/14 to 5/1/2015. Outpatients underwent THA at a newly opened ambulatory surgery center. Inpatients underwent THA in a hospital setting. Ninety-six outpatients and 152 inpatients between the ages of 29–65 years old were included. The Oxford Hip,
Introduction. Circular frames in the lower limbs have been removed by Specialist nurses in our clinics for the past 20 years using Entonox. This standard of care has helped reduce the burden of health care cost by avoiding removal of frames in theatres. We have recently started using Penthrox and present our encouraging initial data suggestive of superior efficacy when compared to Entonox. Materials and Methods. We included in this study the last ten patients on whom Entonox was used during frame removal and the first ten patients on whom Penthrox was used. Visual analogue pain scale was used to quantify pain at the beginning, middle and at the end of frame removal in both groups. The data was found to be normally distributed and Unpaired T test was used to analyse it. Confidence interval of 95% and p-value 0.05 deemed significant. Results. At the beginning of frame removal the Entonox group had a mean VAS score of 5.3 and Penthrox group had 3 (p-value 0.1194). During the middle of frame removal the Entonox group had a mean VAS score of 7.3 and Penthrox group had 4.5 (p-value 0.0379, statistically significant). At the end of frame removal the Entonox group had a mean VAS score of 4.2 and Penthrox group had 2.3 (p-value 0.1734). Penthrox group showed a statistically significant improvement in the mean
The relationship between pain catastrophising and emotional disorders including anxiety and depression in patients with osteoarthritis (OA) undergoing total joint replacement (TJR) is an emerging area of study. The purpose of this study was to examine the association between pain catastrophising, anxiety, depression and preoperative patient characteristics. A prospective cohort study of preoperative TJR patients at one centre over 12-months was conducted. We examined association between catastrophising, anxiety, depression and preoperative patient characteristics including demographics, pain and function. Pain catastrophising was assessed using the Pain Catastrophising Scale (PCS), and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). Patient perceived level of hip/knee pain was measured using a visual analogue (VAS) pain scale. Patient perception of function was measured using the Oxford Score. Preoperative radiographic grading of OA was determined using the Kellgren and Lawrence (K-L) scale. Logistic regression was used to assess pattern of relationship between preoperative characteristics and PCS or HADS. Adjusted odds ratio (OR) and 95% confidence interval (CI) were reported. A secondary quantile regression analysis examined whether a model not restricted to pre-defined PCS and HADS categories would yield comparable results to the logistic regression model described in the primary analysis. P-values less than 0.05 were considered statistically significant. The sample included 463 TJR patients (178 hips, 285 knees).
Introduction. Outpatient total joint arthroplasty (TJA) is emerging as a viable alternative to the historically accepted hospital-based inpatient TJA in the United States. Several studies have focused on the financial advantages of outpatient TJA, however little research has discussed patient reported outcome measures (PROM) and the overall patient experience. The purpose of this study is to compare PROM data in patients undergoing outpatient vs. inpatient total knee arthroplasty (TKA) performed in the first year of a newly opened outpatient facility. Methods. An internal quality metric database analysis was performed on patients undergoing TKA between 2/14/14 and 5/1/2015. Outpatient TKA was performed at an ambulatory surgery center. Three-hundred and forty-three TKA patients (both inpatient and outpatient) between the ages of 37–65 years old were included. The Oxford Hip,
Background. Peri-prosthetic humerus fractures are relatively uncommon occurrences that can be difficult to manage non-operatively. Locking plate technology has enhanced the surgical management of these fractures. We describe an osteosynthesis technique utilizing a locking plate with eccentrically placed screw holes to place “skive screws” in the proximal end of the plate to achieve fixation around the stem of the implant. Methods. A retrospective review of prospectively collected data was performed for a consecutive series of patients treated with this skive screw technique from May 2011 to September 2014. Seven patients presented with postoperative type B peri-prosthetic humerus fractures. Average follow-up was 24 months. Radiographic analysis was performed on most recent postoperative imaging. Clinical outcomes were assessed using
Perioperative glucocorticoids have been used as a successful non-opioid analgesic adjunct for various orthopaedic procedures. Here we describe an ongoing randomized control trial assessing the efficacy of a post-operative methylprednisolone taper course on immediate post-operative pain and function following surgical distal radius fixation. We hypothesize that a post-operative methylprednisolone taper course following distal radius fracture fixation will lead to improved patient pain and function. This study is a randomized control trial (NCT03661645) of a group of patients treated surgically for distal radius fractures. Patients were randomly assigned at the time of surgery to receive intraoperative dexamethasone only or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course. All patients received the same standardized perioperative pain management protocol. A pain journal was used to record
Background. The purpose of this study was to determine if thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) and American Shoulder and Elbow Surgery (ASES) score exist that predict “excellent” patient satisfaction (PS) following reverse total shoulder arthroplasty (RSA). Methods. Patients undergoing RSA using a single implant system were evaluated pre-operatively and at a minimum 2-year follow-up. Receiver-operating-characteristic (ROC) curve analysis determined thresholds to predict “excellent” PS by evaluating the percentage of maximal improvement for SST and ASES. Pre-operative factors were analyzed as independent predictors for achieving SST and ASES thresholds. Results. 198 (SST) and 196 (ASES) patients met inclusion criteria. For SST and ASES, ROC analysis identified 61.3% (p<.001) and 68.2% (p<.001) maximal improvement as the threshold for maximal predictability of “excellent” satisfaction respectively. Significant positive correlation between the percentage of maximum score achieved and “excellent” PS for both groups were found (r=.440, p<.001 for SST score; r=0.417, p<.001 for ASES score). Surgery on the dominant hand, greater baseline
Compared to single-incision distal biceps repair (SI), double-incision repair (DI) theoretically allows for reattachment of the tendon to a more anatomically favorable position. We hypothesized that DI repair would result in greater terminal supination torque compared to SI repair for acute distal biceps ruptures. In this retrospective cohort study, patients were included if they sustained an isolated, acute (° supinated position. Secondary outcomes included supination torque in 45° supinated, neutral, and 45° pronated positions, ASES elbow score, DASH, SF-12, and VAS. Power analysis revealed that at least 32 patients were needed to detect a minimum 15% difference in the primary outcome (β = 0.20). Statistical analysis was performed with significance level α = 0.05 using R version 3.4.1 (R Core Team 2017, Vienna, Austria). Of 53 eligible patients, 37 consented to participate. Fifteen were repaired using DI technique and 22 using SI technique. Mean age was 47.3yrs and median follow-up time was 28.1months. The groups did not differ with respect to age, time-to-follow-up, dominance of arm affected, Workers Compensation or smoking status. Mean supination torque, measured as the percentage of the unaffected side, was 60.9% (95%CI 45.1–76.7) for DI repair versus 80.4% (95%CI 69.1–91.7) for SI repair at the 60°supinated position (p=0.036). There were no statistically significant differences in mean supination torque at the 45°supinated position: 67.1% (95%CI 49.4–84.7) for DI versus 81.8% (95%CI 72.2–91.4) for SI (p=0.102), at the neutral position: 88.8% (95%CI 75.2–102.4) for DI versus 97.6% (95%CI 91.6–103.7) for SI (p=0.0.170), and at the 45°pronated position: 104.5% (95%CI 91.1–117.9) for DI versus 103.4 (95%CI 97.2–109.6) for SI (p=0.0.862). No statistically significant differences were detected in the secondary outcomes ASES Pain, ASES Function, DASH scores, SF-12 PCS or MCS, or
Compared to single-incision distal biceps repair (SI), double-incision repair (DI) theoretically allows for reattachment of the tendon to a more anatomically favorable position. We hypothesized that DI repair would result in greater terminal supination torque compared to SI repair for acute distal biceps ruptures. In this retrospective cohort study, patients were included if they sustained an isolated, acute (° supinated position. Secondary outcomes included supination torque in 45° supinated, neutral, and 45° pronated positions, ASES elbow score, DASH, SF-12, and VAS. Power analysis revealed that at least 32 patients were needed to detect a minimum 15% difference in the primary outcome (β = 0.20). Statistical analysis was performed with significance level α = 0.05 using R version 3.4.1 (R Core Team 2017, Vienna, Austria). Of 53 eligible patients, 37 consented to participate. Fifteen were repaired using DI technique and 22 using SI technique. Mean age was 47.3yrs and median follow-up time was 28.1months. The groups did not differ with respect to age, time-to-follow-up, dominance of arm affected, Workers Compensation or smoking status. Mean supination torque, measured as the percentage of the unaffected side, was 60.9% (95%CI 45.1–76.7) for DI repair versus 80.4% (95%CI 69.1–91.7) for SI repair at the 60°supinated position (p=0.036). There were no statistically significant differences in mean supination torque at the 45°supinated position: 67.1% (95%CI 49.4–84.7) for DI versus 81.8% (95%CI 72.2–91.4) for SI (p=0.102), at the neutral position: 88.8% (95%CI 75.2–102.4) for DI versus 97.6% (95%CI 91.6–103.7) for SI (p=0.0.170), and at the 45°pronated position: 104.5% (95%CI 91.1–117.9) for DI versus 103.4 (95%CI 97.2–109.6) for SI (p=0.0.862). No statistically significant differences were detected in the secondary outcomes ASES Pain, ASES Function, DASH scores, SF-12 PCS or MCS, or
Introduction. The Accolade II taper stem incorporates design features which maximize proximal stem fit and bone contact and avoids more distal taper engagement which has been shown to be problematic. RSA was used in this study to analyze stem micromotion to 2 years post-surgery, providing an indication of long-term fixation. Pain, function and health-related quality of life were also compared before and after total hip arthroplasty (THA.). Method. This prospective, single centre case-series enrolled 35 patients into Parts A and B. The first 5 subjects were recruited to Part A of the study (learning curve), the subsequent 30 patients to part B. Radiopaque tantalum beads were inserted intra-operatively into each patient, with RSA radiographs taken immediately post-operatively, and at 3, 6, 12 and 24 months. These radiographs were digitized to DICOM file format and exported, allowing for independent analysis using the UmRSA system. Three Patient Reported Outcome Measurements; WOMAC, EQ-5D-3L and
Introduction:. The direct anterior approach for total hip arthroplasty has shown to improve multiple early outcome measures. However, criticisms suggest improved results may be due to selection bias and protocol changes. This study compares mini-incision posterior approach to direct anterior approach performed by one surgeon, controlling for influences other than the surgical approach itself. Methods:. An IRB approved retrospective review was conducted on 150 consecutive primary total hip arthroplasty patients; the first 50 from mini-incision posterior approach, followed by 50 during the learning curve for direct anterior approach, and 50 subsequent cases when the approach was routine. Peri-operative protocols were alike for all groups. Data collection included patient demographics, anesthesia, operative times, discharge disposition, length of stay,
Background. Opiate abuse is a rapidly growing epidemic in the US, and orthopaedic surgeons are among the highest prescribers. While surgeons have relied heavily on opiates after total hip replacement (THR), our goal was to determine whether a multimodal pain regimen could improve pain control and reduce or even obligate the need for opiates. Methods. In a cluster-randomised, crossover trial, we assigned 235 patients undergoing THR to receive either a multimodal pain regimen with a minimal opiate supply (Group A- 10 tablets only), a conventional multimodal regimen (Group B- 60 tablets), or a traditional opiate regimen without multimodal therapy (Group C- 60 tablets). Clusters were determined by surgeon, with each cluster alternating between regimens in 4-week intervals. The multimodal pain regimen comprised standing-dose acetaminophen, meloxicam, and gabapentin. Primary outcomes were
Background:. Massive rotator cuff tear can cause functional disability due to instability and degenerative changes of the shoulder joint. In patients with massive irreparable rotator cuff tear, tendon transfer is often used as the salvage procedure. Latissimus dorsi and pectoris major transfer are technically demanding procedures and may incur complications. The biceps tendon transfer may provide a biologically superior tissue patch that improves the biomechanics of the shoulder joint in patients with irreparable rotator cuff tear. This study evaluated the functional outcomes of biceps tendon transfer for irreparable rotator cuff tear in 6 patients with two years and longer follow-up. Methods:. Between September 2006 and October 2011, 50 patients with 50 shoulders underwent surgical repair for MRI confirmed rotator cuff tear. Among them, six patients with massive irreparable rotator cuff tear were identified intraoperatively, and underwent proximal biceps tendon transfer to reconstruct the rotator cuff tear. The biceps tendon was tenodesed at the bicipital groove, and the proximal intra-articular portion of the biceps tendon was transected. The biceps graft was fanned out and the distal end fixed to the cancellous trough around the greater tuberosity with suture anchor. The anterior edge was sutured to the subscapularis and the posterior edge to the infraspinatus tendon or supraspinatus if present. Postoperative managements included sling protection and avoidance of strenuous exercises for 6 weeks, and then progressive rehabilitation until recovery. Results:. The evaluation parameters included
Background. Total Knee Arthroplasty (TKA) provides patients with significant improvements in quality of life. Subjective patient reported outcome measures (PROMs) are traditionally used to measure preoperative functional status and postoperative outcomes. However, there are limitations to PROMs. In particular, they provide virtually no functional information in the first 3 weeks after surgery, which could be used to guide the patient's recovery. Newly available wearable electronic sensors make it possible to: 1) measure important functional outcomes following TKA; 2) guide the patient's physical therapy (PT); and 3) provide real-time functional and clinical information to the provider. Compliance with PT after TKA is a challenge. Patients cite time, transportation, and cost as deterrents to PT appointments. However, an intensive PT program is essential in TKA. Surface sensor devices may be able to increase PT compliance by guiding patients through exercises at home. Additionally, these devices can transmit PT progress in real-time to the providers, allowing them to monitor and assist the patient's recovery. Our study investigates the feasibility of using a surface sensor device (TracPatch™) on patients following TKA. We sought to answer the following questions: 1) Will patients tolerate the device; 2) Will patients comply with device instructions; 3) Will patients be able to use the smart phone application; 4) Will the device collect, transmit, and store data as it was designed? We believe these fundamental questions must be answered as we enter the era of personal sensor-measured functional outcomes. Methods. 20 patients undergoing primary, unilateral TKA were enrolled in this IRB approved study. At the pre-surgical visit, patients were given instructions for the device and smart phone application. Each patient used the device in the week prior to surgery, and data was collected. The device was again applied in the operating room. For 3 weeks post-operatively, the device collected functional data, along with WOMAC, OKS, KSS, PROMIS, and
