Septic Arthritis (SA) is considered a surgical urgency/ emergency by physicians around the world. As our understanding grows, and improved diagnostic algorithms are developed, it has become apparent that competing interests in terms of accurately diagnosing concurrent osteomyelitis may supercede rapid surgical intervention when the imaging is timely. Nevertheless, even in cases of isolated SA, many patients will require repeat surgery. We aimed to assess factors which could predict this.

A multicenter retrospective redcap database was created involving 20 pediatric centers from the CORTICES study group with the goal of better understanding pediatric musculoskeletal infection (PMSKI). All patients who met inclusion for the database were considered, surgeons for each site determined through imaging and chart review which patients met the diagnosis of isolated SA. Patients with concomitant abscesses or osteomyelitis were expressly excluded. Appropriate non parametric statistics were used to assess univariate significance. Multivariable logistic regression was used to assess clinical factors associated with an increased likelihood of more than one surgery. Receiver characteristics operating curve (ROC) analysis was used to determine optimal cutoffs to discriminate between children who required more than one surgery compared to those who required only one surgery. A probability algorithm was developed for the number of clinical factors present and the likelihood requiring more than one surgery following SA diagnosis.

“Four hundred and fifty-four patients with isolated SA were analyzed from 20 US hospitals. Patients were 5.4 +/− 4.8 years old at admission, and the cohort was 56% male. Of the 454 patients, 47 (10.4%) needed more than one surgery. Bivariate comparisons across surgery groups found significant differences in minimum platelet count (pplatelet, a patient has a 0.3% reduction in the odds of needing more than one surgery (OR=.997; p=0.04). For each additional ten units of CRP, a patient has a 0.1% increase in the odds of needing more than one surgery (OR=1.001; p<0.001). Our predictive algorithm found that children with both risk factors had a 64% chance of requiring multiple surgeries.

Higher CRP values and lower platelet values indicate more severe disease in isolated SA with a greater likelihood of repeat surgery. Higher CRP and lower platelet counts may portend multiple surgeries and caregivers of children with isolated SA should be advised as such.

Sixty four patients undergoing total hip replacement (THR) were randomized to receive a peri-articular intra-operative multi modal drug injection or to receive no injection. All patients received patient controlled analgesia (PCA) for 24 hours after surgery.

Patients receiving the peri-articular injection showed significantly less PCA consumption 6 hours postoperatively (P< 0.002). The 24 hour PCA requirement post surgery was also less (P< 0.009).

The VAS score for pain on activity in the post anaesthetic care unit (PACU) was significantly less for injected patients (P< 0.04). The VAS satisfaction score for injected patients in the PACU and 4 hours post-operatively showed no statistical difference.

Peri-articular intra-operative injection with multimodal drugs can significantly reduce post-operative patient controlled analgesia requirements and pain on activity in patients undergoing total hip replacement with no apparent increase in risk.

Rotator cuff tears are a common cause of shoulder pain and dysfunction. Therefore, the purpose of this in-vitro biomechanical study was conducted to determine the effects of simulated tears and subsequent repairs of the rotator cuff tendons on joint kinematics.

Eight paired fresh-frozen cadaveric shoulder specimens (mean age: 66.0 ± 8.7 years) were tested using a custom loading apparatus designed to simulate unconstrained motion of the humerus. Cables were sutured to the rotator cuff tendons and the deltoid. Loads were applied to the cables based on variable ratios of electromyographic (EMG) data and average physiological cross-sectional area (pCSA) of the muscles. An electromagnetic tracking device (Flock of Birds, Ascension Technologies, VT) was used to provide real-time feedback of abduction angle, to which the loading ratio was varied correspondingly. 2 and 4cm tears were made starting at the rotator cuff interval and extending posteriorly. Specimens were randomised to receive either single or double suture anchor repair. In order to quantify repeatability, five successive tests on each of the intact, torn, and repaired cases were performed. Statistical significance was established using One- and Two-way Repeated Measured ANOVAs (p< 0.05).

Rotator cuff tears caused alteration in glenohumeral kinematics. A 2cm tear caused the humerus to consistently move posterior through the arc of abduction; however, as the tear increased to 4cm the humerus moved anteriorly, returning towards the intact state. Double row suture anchor repairs more accurately reproduced the kinematics of the intact specimen compared to single row suture anchor repair.

The initial posterior displacement in the plane of elevation with the sectioning of the supraspinatus is related to the diminished anterior moment on the glenohumeral joint. As the tear proceeds into the infraspinatus, the anterior and posterior forces become more balanced and a return to near normal intact kinematics was observed. This study demonstrates that double row suture anchor repair more accurately reproduces active shoulder kinematics of the intact shoulder specimens.

Purpose: Metal radial head arthroplasty is a proven technique for the treatment of complex radial head fractures. Little previous research is available on the utility and longevity of metal radial head arthroplasty for elbow reconstruction. The purpose of this study was to evaluate the functional outcome of patients with metal radial head arthroplasty (RHA) for elbow reconstruction.

Methods: This was a retrospective review from one institution with three senior orthopaedic surgeons. 23 consecutive patients with 23 RHA were included in the study, 4 patients were lost to follow up. RHA was performed for conditions of rheumatoid arthritis, post traumatic radial head nonunion, post traumatic radial head malunion, elbow instability following previous radial head excision and failed silicone radial head implants. Patients were excluded from the study if they were treated for an acute injury with RHA (under 2 months from injury). There were 8 males and 15 females with a minimum of 2 year follow up. Analysis included chart review, personal interview, physical examination, radiographs and strength testing. Region specific questionnaires were used including: DASH, ASES, MEPI, PRWE, WOS and SF-36. Mean follow up was 9 yrs.

Results: Mayo elbow performance scores were excellent in 11 patients, good in 4 patients, fair in 4 patients and poor in 4 patients. Subjective patient satisfaction was averaged at 8.4 out of 10. Patients demonstrated significantly less isometric strength and grip strength in the affected versed unaffected elbow. There was no statistically significant difference seen in ulnar variance or ulnohumeral joint space between the affected and unaffected limbs.

Conclusions: In conclusion, RHA for elbow reconstruction is a safe procedure that provides patients with long term functional ROM and pain relief.

This Blinded Randomized Clinical Trial outlines: how peri-articular intra-operative multimodal analgesia significantly reduces post-operative analgesia requirement. Sixty-four patients undergoing total knee replacement were randomised to receive a peri-articular intra-operative injection containing ropivacaine, ketorolac, epimorphine and epinephrine or nothing. Patients who received the injection demonstrated greater satisfaction and pain relief. Finally, patients in the injected group did not show any signs of cardio and central nervous system toxicity.

Post-operative analgesia can be associated with troublesome side effects. Good peri-operative analgesia facilitates rehabilitation, improves patient satisfaction and may reduce hospital stay. The purpose of this study was to assess a novel cocktail for peri-articular analgesia after total knee replacement.

Sixty-four patients undergoing total knee replacement were randomised to receive a peri-articular intra-operative injection containing ropivacaine, ketorolac, epimorphine and epinephrine or nothing. The anaesthetic analgesic regime was standardised. All patients received patient controlled analgesia (PCA) for twenty-four hours post surgery, followed by standard analgesia. VAS pain scores during activity and at rest and patient satisfaction scores were recorded pre and post operatively and at six week follow up. PCA consumption and overall analgesic requirement were measured.

PCA use at six, twelve and over twenty-four hours post surgery was significantly less in patients receiving the injection (p< 0.01, p=0.016, p< 0.01). Patient satisfaction in PACU and four hours post operation was greater (p=0.016, p=0.013). VAS for pain during activity in PACU and at four hours were significantly less (p=0.04, p=0.007) in the injected group. The average ROM at six weeks was no different. Overall hospital stay and the incidence of wound complications were not different between the two groups.

Peri-articular intra-operative multimodal analgesia significantly reduces post-operative analgesia requirement. Patient satisfaction and pain relief is greater in the injection group. No cardio and central nervous system toxicity was observed.

Our novel cocktail of ketorolac, epimorphine, epinephrine and ropivacaine provides superior pain relief with no adverse side effects.

Purpose: Post-operative analgesia using opioids or epidural analgesia can be associated with troublesome side effects. Effective peri-operative analgesia facilitates rehabilitation, improves patient satisfaction and may reduce hospital stay. Locally administered analgesia is effective, avoids systemic drug related side-effects and may be of benefit in minimally invasive joint replacement. This study compares the effects of a peri-articular injection cocktail in patients undergoing total knee and hip replacement surgery

Methods: 128 patients undergoing total knee (TKR) and hip (THR) replacement were randomised to receive a peri-articular intra-operative injection containing ropivacaine, ketorolac, epimorphine and epinephrine or nothing. The anaesthetic analgesic regime was standardised. All patients received patient controlled analgesia (PCA) for 24 hours post surgery, followed by standard analgesia. VAS pain scores during activity and at rest and patient satisfaction scores were recorded pre and post operatively and at 6 week follow up. PCA consumption and overall analgesic requirement were measured.

Results: Both TKR and THR patients used significantly less PCA 6 hours after surgery (p = 0.02 THR, p< 0.01 TKR). TKR patients receiving the injection used significantly less PCA use over 24 hours post surgery (p = 0.013). VAS for pain at 4 hrs post operation was significantly lower in the both groups (p = 0.003 TKR)(p = 0.017 THR). VAS for pain during activity at 24 hours was significantly less (p = 0.001) in the injected TKR group. Overall hospital stay and wound complications were not different between the groups.

Conclusions: Peri-articular analgesia significantly reduces post-operative analgesia requirement in TKR and THR patients. Greater satisfaction and pain relief was seen in TKR patients compared with THR.

Introduction: Post-operative analgesia using parenteral opioids or epidural analgesia can be associated with troublesome side effects. Good peri-operative analgesia facilitates rehabilitation, improves patient satisfaction and may reduce hospital stay. Locally administered pre-emptive analgesia is effective, reduces central hyper-sensitisation and avoids systemic drug related side-effects and may be of benefit in minimally invasive joint replacement.

Materials and methods: 64 patients undergoing total knee replacement were randomised to receive a peri-articular intra-operative injection containing ropiva-caine, ketorolac, epimorphine and epinephrine. The anaesthetic analgesic regime was standardised. All patients received patient controlled analgesia (PCA) for 24 hours post surgery, followed by standard analgesia. VAS pain scores during activity and at rest and patient satisfaction scores were recorded pre and post operatively and at 6 week follow up. PCA consumption and overall analgesic requirement were measured.

Results: PCA use over 24 hours post surgery was significantly less in patients receiving the injection (P=0.013). Patient satisfaction at 4 hrs post operation was greater (P=0.003). VAS for pain during activity at 4 hrs and 24 hours were significantly less (P=0.001) in the injected group. The average ROM at 6 weeks was no different. Overall hospital stay and the incidence of wound complications was not different between the 2 groups.

Discussion: Peri-articular intra-operative multimodal analgesia significantly reduces post-operative analgesia requirement. Patient satisfaction is greater in the injection group. No cardio and central nervous system toxicity was observed.