Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach.

Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption.

During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively.

For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control.

The absence of menisci in the knee leads to early degenerative changes. Complete radial tears of the meniscus are equivalent to total meniscectomy and repair should be performed if possible. The purpose of this study was to biomechanically compare the cross suture, hashtag and crosstag meniscal repairs using all-inside implants for radial tears.

Radial tears were created at the mid-body of 36 fresh-frozen lateral human menisci and then repaired, in randomiSed order, with Fast-Fix™ 360s (Smith & Nephew, Andover, MA) using the cross suture, hashtag and crosstag techniques. The repaired menisci were tested using an Instron Electropuls E10000 (Instron, Norwood, MA). The tests consisted of cyclic loading from 5 to 30N at 1Hz for 500 cycles, then a load to failure test. Displacement following cyclic loading, load at 3mm of displacement, load to failure, and stiffness were recorded. Any differences between repairs were assessed using Kruskal-Wallis and Mann Whitney tests (p<0.05).

Cross suture repairs displaced more following cyclic loading and resisted less load to failure than both the hashtag and crosstag repairs. However, these differences were not statistically significant. The average displacement following cyclic loading of cross suture, hashtag, and crosstag repairs was 4.34 mm (±2.02 mm), 3.46 mm (±2.12 mm), and 3.24 mm (±1.52 mm) respectively (p=0.33). Maximal load to failure was 64.83 N (±17.41 N), 74.52 N (±9.03 N), and 74.98N (±10.50N), respectively (p=0.419).

All-inside cross suture, hashtag and crosstag repairs all displaced >3mm with cyclic loading, which is the threshold for meniscal insufficiency. This contrasts previous studies using inside-out sutures, where crosstag and hashtag repairs resisted cyclic loading (< 3mm). Inside-out suturing for radial tears of the lateral meniscus currently remains the gold standard.

In this study, we describe a morphological classification for greater tuberosity fractures of the proximal humerus. We divided these fractures into three types: avulsion, split and depression. We retrospectively reviewed all shoulder radiographs showing isolated greater tuberosity fractures in a Level I trauma centre between July 2007 and July 2012. We identified 199 cases where records and radiographs were reviewed and included 79 men and 120 women with a mean age of 58 years (23 to 96). The morphological classification was applied to the first 139 cases by three reviewers on two occasions using the Kappa statistic and compared with the AO and Neer classifications. The inter- and intra-observer reliability of the morphological classification was 0.73 to 0.77 and 0.69 to 0.86, respectively. This was superior to the Neer (0.31 to 0.35/0.54 to 0.63) and AO (0.30 to 0.32/0.59 to 0.65) classifications. The distribution of avulsion, split and depression type fractures was 39%, 41%, and 20%, respectively. This classification of greater tuberosity fractures is more reliable than the Neer or AO classifications. These distinct fracture morphologies are likely to have implications in terms of pathophysiology and surgical technique.

Cite this article: Bone Joint J 2014;96-B:646–51.