Peri-Operative Management of Periacetabular Osteotomy: A Report of Current Practices from the Anchor Group, Supporting Literature, and Areas for Future Investigation.

Background: Periacetabular osteotomy (PAO) is a well-established surgical treatment for hip dysplasia, but very few studies report the impact of peri-operative management strategies on early pain and function. The purpose of this study is to describe peri-operative management variability among a group of experienced surgeons and review the literature supporting these practice patterns. Methods: We surveyed 16 surgeons that perform PAO to document various aspects of peri-operative management at four stages: pre-operative, intra-operative, post-operative in the hospital, and at discharge. Our goal was to report current surgical pain management strategies, adjunct medications, type of anesthesia, deep venous thrombosis and heterotopic ossification prophylaxis strategies, initiation of physical therapy, and use of continuous passive motion (CPM). We reviewed current literature to identify studies supporting these perioperative strategies and identify knowledge gaps that would benefit from further investigation. Results: Of the 16 surgeons surveyed, 75% had been in practice greater than 10 years and most had not altered their post-operative protocol for more than 3 years. 15/16 surgeons felt that length of stay could be reduced at their institution with improved peri-operative pain management. 6/16 were considering or had already implemented outpatient PAO as a part of their practice. We found significant variability in the pain medications provided at all peri-operative stages. 14/16 utilized general anesthesia, and many utilized epidural or peripheral nerve blocks. 6/16 surgeons utilized surgical field block (also referred to as periarticular block). These surgeons advocated that surgical field block was an effective intervention with no/minimal complication risk. There is very little literature critically evaluating efficacy of these perioperative management strategies for PAO. Conclusion: There is significant practice variability in peri-operative management of PAO surgery. We report various strategies utilized by a group of experienced surgeons and review supporting literature. There are significant knowledge gaps in best surgical pain management strategies, adjunct medications, surgical field blocks, and use of CPM that need further investigation. Level of Evidence: IV.

Knee braces and foot orthoses multimodal 3-month treatment of medial knee osteoarthritis in a randomised crossover trial.

PURPOSE: Immediate biomechanical and functional benefits of knee braces and lateral wedge foot orthoses (FO) are often reported on patients with medial knee osteoarthritis. However, the effectiveness of their combined use in a longer-term orthotic treatment remains unclear. The aim was to evaluate pain, function, comfort and knee adduction moment (KAM) during the stance phase of gait with three modalities of orthotic treatment. METHODS: Twenty-two patients with knee osteoarthritis were analysed in a randomised crossover trial including a knee brace with valgus and external rotation functions (VER), FO and their combined use (VER + FO). Western Ontario and McMaster Universities scale (WOMAC) and Knee injury and Osteoarthritis Outcome Scores and KAM during gait were obtained before and after each orthotic treatment of 3 months. Repeated measures analyses of variance contrasted the factors orthosis (VER, FO, VER + FO), treatment (pre and post) and wear (without and with) on pain, function, comfort and KAM. RESULTS: An interaction between orthosis and treatment on the WOMAC pain (effect size [ES] = 0.17) and a main effect on the pain visual analogue score (ES = 0.24) indicated that VER and VER + FO were more alleviating than FO. The three modalities of orthotic treatment significantly improved functional scores (ES > 0.2) and reduced discomfort (ES = 0.25). A significant multivariate interaction between orthosis and wear (ES = 0.73) showed that the KAM reduction while wearing the orthoses was more pronounced with the VER and VER + FO than the FO. CONCLUSION: The VER-brace obtained more effectiveness than FO on pain and KAM after 3 months for medial knee osteoarthritis and the combined treatment did not substantially improve biomechanical and functional outcomes. LEVEL OF EVIDENCE: Therapeutic study level I randomised crossover trial.

The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multicenter Randomized Clinical Trial.

BACKGROUND: A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary end point being the International Hip Outcome Tool-33 at 1 year. METHODS: In a multicenter study, 203 patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years [range, 16 to 44]; mean body mass index of 25.1 [range, 18.3 to 37.2]; 86% women) and 91 patients undergoing PAO who had an arthroscopy (mean age 27 years [range, 16 to 49]; mean body mass index of 25.1 [17.5 to 25.1]; 90% women). RESULTS: At a mean follow-up of 2.3 years (range, 1 to 5), all patients exhibited improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months postsurgery on all scores: preoperative International Hip Outcome Tool-33 score of 31.2 (standard deviation [SD] 16.0) versus 36.4 (SD 15.9), and 12 months postoperative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6). The preoperative Hip disability and Osteoarthritis Outcome pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0) and 12 months postoperative 88.2 (SD 15.8) versus 88.4 (SD 18.3). The mean preoperative physical health Patient-Reported Outcomes Measurement Information System score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months postoperative 48.7 (SD 8.5) versus 52.0 (SD 10.6). There were 4 patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and 1 patient from the PAO plus arthroscopy group required an additional arthroscopy. CONCLUSIONS: This randomized controlled trial has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at 1-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Lower limbs biomechanical deficits associated with stage 1 and 2 posterior tibialis tendon dysfunction during walking.

BACKGROUND: Posterior tibialis tendon dysfunction (PTTD) is a chronic degenerative musculoskeletal disorder causing a progressive ankle complex and arch collapse altering lower limb biomechanics. However, biomechanical changes associated with stage 1 and 2 PTTD need to be better characterized during walking to guide clinical recommendations and improve non-operative treatments. RESEARCH QUESTION: What are the lower limb kinematic and kinetic differences between individuals with stage 1 (PTTD1), individuals with stage 2 PTTD (PTTD2) and healthy counterparts during gait? METHODS: Sixteen PTTD1, 11 PTTD2 and 20 healthy controls were included in this multicentric case-control study to compare their lower limb gait biomechanics. Kinematic and kinetic data were recorded using a three-dimensional motion capture system and a force plate. One-dimensional statistical parametric mapping was used to compare lower limb joint motion and moments between groups during the stance phase. RESULTS: PTTD1 had minimal biomechanical differences compared with the control group. In contrast, PTTD2 presented significant differences compared with controls and PTTD1. At the ankle, PTTD2 exhibited greater plantarflexion and eversion angles and midfoot dorsiflexion and inversion angles throughout stance compared with controls and PTTD1. PTTD2 presented lower midfoot abduction moments compared with controls. These changes led PTTD2 to exhibit knee and hip adaptative biomechanical mechanisms in the frontal and transverse planes in late stance. PTTD2 had greater knee internal rotation angles and smaller knee external rotation moments compared to controls. PTTD2 had smaller hip internal rotation angles compared with PTTD1 and smaller hip adduction moments compared with controls. SIGNIFICANCE: PTTD1 showed minimal biomechanical differences compared to controls and important differences compared to PTTD2. The lower limb biomechanical deficits accentuate as the pathology advances from stage 1 to stage 2. PTTD is a progressive condition needing early clinical management at stage 1 to avoid successive biomechanical changes associated with stage 2.

Sleep Apnea is Not an Obstacle for Outpatient Hip and Knee Arthroplasty.

BACKGROUND: Up to 25% of patients requiring hip or knee arthroplasty have sleep apnea (SA), and these patients have historically been excluded from outpatient programs. The objectives of this study were to evaluate same-day discharge failure as well as 30-day complications, readmissions, and unexpected visits. METHODS: A retrospective case-control study comparing patients who have and do not have SA matched for age, sex and arthroplasty type (total hip arthroplasty, total knee arthroplasty, unicompartimental knee arthroplasty) who underwent primary outpatient surgery between February 2019 and December 2022 in 2 academic hospitals was conducted. Cases with mild SA, moderate SA with a body mass index (BMI) <35, and SA of all severity treated by continuous positive airway pressure machines were eligible. There were 156 patients included (78 cases). Complications were assessed according to the Clavien-Dindo Classification and the Comprehensive Complication Index. Continuous variables were evaluated by Student's T or Mann-Whitney tests, while categorical data were analyzed by Chi-square or Fisher tests. Univariate analyses were performed to determine discharge failure risk factors. RESULTS: There were 6 cases (7.7%) and 5 controls (6.4%) who failed to be discharged on surgery day (P = .754), with postoperative hypoxemia (6, [3.8%]) and apnea periods (3, [1.9%]) being the most common causes. Higher BMI (odds ratio = 1.19, P = .013) and general anesthesia (odds ratio = 11.97, P = .004) were found to be risk factors for discharge failure. No difference was observed on 30-day readmissions (P = .497), unexpected visits (P = 1.000), and complications on the Clavien-Dindo Classification (P > .269) and Comprehensive Complication Index (P > .334) scales. CONCLUSIONS: Selected patients who have SA can safely undergo outpatient hip or knee arthroplasty. Higher BMI and general anesthesia increased the odds of same-day discharge failure. LEVEL OF EVIDENCE: Level III, Case-control Study.

Gait pattern analysis before and after periacetabular osteotomy in unilaterally affected dysplastic patients.

BACKGROUND: Patients with acetabular dysplasia have an abnormal acetabular geometry which results in insufficient coverage of the femoral head. This coverage deficiency reduces contact surfaces within the joint, accelerating the wear of the articular cartilage and predisposing patients to early osteoarthritis. Periacetabular osteotomy is a surgical treatment of acetabular dysplasia that aims to reorient the acetabulum relative to the femoral head, increasing coverage. METHODS: Pelvic kinematics and lower limbs joint kinematics and kinetics during the stance phase of gait were recorded using a 3D motion capture system and force plates, then compared pre- to post- and between limbs with a repeated measures 2-way ANOVA. Radiographic measurements and gait parameters were compared pre- to post-surgery using a t-test for dependant samples. To identify predictors of pelvic symmetry improvements during gait, a multivariate analysis was performed using a forward stepwise linear regression. FINDINGS: Radiographic measurements improved for all participants while gait parameters remained unchanged. Hip flexion symmetry was improved following surgery. The external rotation moment of the healthy hip was reduced after surgery (-29%) resulting in increased asymmetry. Pelvic tilt was significantly greater on the affected side (+0.5°) during the loading response, and the difference tended to be greater after surgery (+0.8°). INTERPRETATION: Unilaterally affected dysplastic patients have an asymmetrical gait pattern that is only partially corrected by periacetabular osteotomy even when radiographic and clinical targets are met. Differences between the limbs could be explained in part by a learned antalgic pattern and muscle weaknesses leading to complex compensation mechanisms.

Lateral knee laxity increases the risk of excessive joint line obliquity after medial opening-wedge high tibial osteotomy.

BACKGROUND: Medial opening-wedge high tibial osteotomy (HTO) is a well-recognized treatment for patient with varus knee osteoarthritis. Joint line obliquity has recently been suggested to negatively impact clinical outcomes following HTO, but little is known about what factors lead to increased joint line obliquity. The purpose of the current study was (1) to evaluate whether increased preoperative lateral knee laxity, represented by the joint line convergence angle, results in increased joint line obliquity in a consecutive series of patients treated with HTO and (2) to determine the effect of advanced arthritic changes on joint line obliquity. HYPOTHESIS: Increased joint line convergence angle would be associated with increased joint line obliquity. PATIENTS AND METHODS: All HTOs performed at our center between 2010-2017 were retrospectively reviewed. Patients were excluded if pre- and postoperative standing alignment radiographs were not available. Varus-producing osteotomies were excluded. Patients were subdivided according to their preoperative joint line convergence angle (≤3° or >3°) and the degree of radiographic arthritic change. The primary outcome measure was the postoperative joint line obliquity. Categorical variables were compared using the paired samples t-test. Survival analysis was performed for failure and overall rate of reoperation. RESULTS: During the study period, 90 HTO were performed, and 38 patients (42 knees; M/F: 32/6; mean age: 41.6; mean follow-up: 4.72 years) met the inclusion criteria. The most common surgical indications were varus knee osteoarthritis (n=27, 64.3%) and osteochondritis dissecans (n=7, 8.2%). Patients with a preoperative joint line convergence angle >3° demonstrated significantly greater joint line obliquity postoperatively as compared to those with a joint line convergence angle ≤3° (6.4°±4.6° vs. 2.5°±5.7°, respectively; p=0.02). Patients with advanced arthritic changes had significantly lower preoperative (-3°±3.4° vs. -5.6°±4.1°; p=0.03) and greater postoperative (5.8°±4° vs. 2.2°±6.4°; p=0.04) joint line obliquity as compared to those with minimal arthritic changes. There were 12 complications among the 42 procedures: one conversion to total knee replacement (TKR), one hardware failure (fixation revised), one infection, and 9 hardware removals. Overall survival using conversion to TKR was 96.23% (95% CI 0.92-1.0) at 10 years. DISCUSSION: Lateral knee laxity, as defined by a preoperative joint line convergence angle >3°, and advanced arthritic changes are associated with increased postoperative joint line obliquity following medial opening-wedge high tibial osteotomy. Soft-tissue adaptation should be accounted for in order to avoid excessive joint line obliquity following high tibial osteotomy, and the planned correction should be reduced by 25% in patients with a preoperative joint line convergence angle >3° when templating using standing alignment radiographs. LEVEL OF EVIDENCE: IV.

Level of implementation of pain management and early mobilization strategies to prevent delirium in geriatric trauma patients: A mixed-methods study.

BACKGROUND: Pain management and early mobilization strategies are recommended in clinical practice guidelines for the prevention of delirium in older adults. However, available data on the implementation of these strategies in trauma are limited. AIMS: To describe the use of pain management and early mobilization strategies in older adults at a level I trauma center, as well as the facilitators and barriers to their implementation. METHODS: A convergent mixed methods study was used. Quantitative data were collected from sixty medical records. Qualitative data was collected through a focus group with healthcare providers to explore their perspectives regarding the use of the target practices and on barriers and facilitators to their implementation. Descriptive statistics were calculated, and a thematic analysis using an inductive and deductive interpretative descriptive approach was undertaken. RESULTS: A question on the presence/absence of pain was the most frequently documented pain assessment method. Pain assessment was poorly documented. Frequencies of non-opioid and opioid administrations were similar, but non-pharmacological strategies were not widely used. The first mobilization was performed quickly and was most commonly to a chair. The focus group discussion confirmed many of the data collected in the medical records. Barriers to implementing the targeted strategies were primarily related to organizational context and facilitation processes. CONCLUSIONS: Areas for improvement were identified including pain assessment, the use of non-pharmacological pain management strategies and ambulation as a mobilization strategy. Our findings will serve as a starting point for optimizing and adapting practices for geriatric trauma patients and evaluating their impact.

The impact of Canadian-produced research on the global orthopedic literature: a bibliometric analysis.

BACKGROUND: Little is known about the quality and impact of Canadian-produced research relative to that of other developed nations. The purpose of this study was to determine the contribution of Canadian authors to the orthopedic literature globally and nationally as well as Canada's research productivity in orthopedics. We hypothesized that Canada ranks among the most impactful countries in terms of orthopedic research productivity. METHODS: We performed a bibliometric analysis to identify articles published between 2001 and 2020 in the category of orthopedics. We identified Canada's global rank in terms of overall productivity and assessed the contributions of individual Canadian authors. We also examined the quality of publications as determined by category normalized citation impact (CNCI) and publication in the top quartile of journals (%Q1) in terms of impact factor. In addition, we calculated the percentage of Canadian publications that were in orthopedics. RESULTS: We identified 10 821 orthopedic publications from 2001 to 2020. Canada placed sixth globally in terms of productivity in orthopedic research. The annual productivity of Canadian orthopedic researchers increased over the study period by a factor of 3.2. In terms of research quality, with a %Q1 of 36.5% and a CNCI of 1.22, Canada outperformed Asian countries and the United States; the latter country had a %Q1 of 35.3% and a CNCI of 1.14 over the study period. CONCLUSION: The body of Canadian orthopedic literature has grown consistently over the past 20 years. Despite the overall leadership of the United States and other developed nations such as China and Japan, Canada ranks among the most influential countries in terms of the quality and quantity of orthopedic research.

Bibliometric evaluation of negative publications from orthopedics and traumatology from the ten most influential journals of 2009-2010 and 2019-2020: A comparative study with the "Orthopedics & Traumatology: Surgery & Research" journal, using the same analysis of submitted and accepted articles.

BACKGROUND: There is a paucity of data in the literature regarding negative articles concerning surgery in orthopedics and trauma. Knowledge pertaining to treatments or techniques which confer a beneficial effect remains important, as does knowledge regarding those which have a null or pejorative effect. Thus, this study was carried out on negative articles in order to: (1) determine their proportion in the ten predominant journals concerning orthopedic and trauma surgery; (2) assess variability in their publication rate depending on the journal and the year, and compare their citation rate to that of positive articles; (3) specify whether a positive article was more likely to be cited compared to a negative article; (4) carry out the same bibliometric analysis with the "Orthopedics & Traumatology: Surgery & Research (OTSR)" journal, and detect possible selection bias for negative articles during the review. HYPOTHESIS: There are fewer negative articles than positive articles in the literature relating to orthopedic and trauma surgery. MATERIAL AND METHOD: The study was carried out using the ten orthopedic and trauma surgery journals with the highest impact factors for the year 2021. Two periods were compared, 2009-2010 and 2019-2020. Among the 17,812 publications obtained, 11,962 publications were retained to carry out the analysis (technical notes, meta-analyses, editorials and letters to the editor were all excluded). An analysis using the same method was carried out on the 3,727 articles submitted to OTSR from 2015 to 2021, which made it possible to compare the rejected articles to the accepted articles. RESULTS: Negative articles represented 11% (1,342/12,023) of the literature relating to orthopedic and trauma surgery. There were differences in the rate of publication of negative articles depending on the journals (from 4.04% to 17.14%) (p<0.0001). The negative article publication rate did not change between the two periods studied: 534/4963 articles (10.76%) in 2009-2010 versus 802/6999 (11.46%) in 2019-2020 (p=0.23). Positive articles were not cited more often than negative ones: no significant difference between the Category Normalized Citation Impact (CNCI) classes (respectively for classes 0;1[/[1;2[/≥ 2 with 45.66% 28.22% and 26.12% for negative articles versus 44.90% 27.46% and 27.64% for positive articles [p=0.4]) and the Top10% (with 18.86% for negative articles versus 20.10% for positive ones [p=0.28]). The OTSR journal had a rate of negative articles of 9.46% which was within the average range of the journals studied. A selection bias (p<0.02) for negative articles during the review of the OTSR journal was identified with fewer negative articles accepted (115/1216 [9.46%]) than positive articles (164/1330 [12.33%]). DISCUSSION: The publication of negative articles varies according to the journals and although it is modest, at only 11%, it is essential because it allows us not to repeat errors but also not to bias the carrying out of meta-analyses, and among other things to avoid useless studies. LEVEL OF EVIDENCE: III; case control study from the literature.

Validation of the French version of the Non-Arthritic Hip Score (NAHS) in 113 hip arthroscopy procedures.

BACKGROUND: The Non-Arthritic Hip Score (NAHS) used to evaluate the hip in younger patients is a self-administered questionnaire with 20 items in four sections: pain, symptoms, function, and activities. Although used in France, no transcultural version had been validated. The objective of this study was to translate the NAHS into French then assess the validity, reliability, and sensitivity to change of the French-language version (NAHS-Fr) in younger patients with hip conditions other than osteoarthritis. HYPOTHESIS: The NAHS-Fr demonstrates good validity and reliability when used in younger French-speaking patients with hip pain. MATERIAL AND METHODS: We conducted a prospective observational study in 105 patients (62 males and 43 females) scheduled for surgery on one or both hips (113 hips in total) to treat cam-type femoro-acetabular impingement or labral lesions. Before and 6 months after surgery, each patient completed the NAHS-Fr and Western Ontario and McMaster Osteoarthritis Index (WOMAC). Statistical tests were done to evaluate validity, reliability, and sensitivity to change, as recommended by the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN). RESULTS: The response rate was 100%, confirming that the NAHS-Fr was easy to use. The NAHS-Fr was both valid and reliable. No ceiling or floor effect was detected for the total NAHS-Fr score. All items had Cronbach alpha coefficients greater than 0.8, indicating good internal consistency. External consistency between the NAHS-Fr and WOMAC was negative (-0.676) due to inversely proportional score indexing. Before surgery, the NAHS-Fr and WOMAC scores were strongly and significantly correlated (p<0.0001). The effect size was greater than 0.8, indicating good sensitivity to the change induced by surgery. DISCUSSION: These results confirm the study hypothesis: the NAHS-Fr has the same good psychometric characteristics as does the original version and versions in other languages. The NAHS-Fr is useful for evaluating younger patients with non-osteoarthritic hip pain and can be used by French-speaking surgeons in everyday clinical practice. LEVEL OF EVIDENCE: IV, prospective observational non-comparative cohort study.

The Impact of Age on Clinical Outcomes of Acetabular Microfracture During FAI Surgery.

BACKGROUND: Full-thickness acetabular cartilage lesions are common findings during primary surgical treatment of femoroacetabular impingement (FAI). PURPOSE: To evaluate clinical outcomes after acetabular microfracture performed during FAI surgery in a prospective, multicenter cohort. STUDY DESIGN: Cohort Study; Level of evidence, 3. METHODS: Patients with FAI who had failed nonoperative management were prospectively enrolled in a multicenter cohort. Preoperative and postoperative (mean follow-up, 4.3 years) patient-reported outcome measures were obtained with a follow-up rate of 81.6% (621/761 hips), including 54 patients who underwent acetabular microfracture. Patient characteristics, radiographic parameters, intraoperative disease severity, and operative procedures were analyzed. Propensity matching using linear regression was used to match 54 hips with microfracture to 162 control hips (1:3) to control for confounding variables. Subanalyses of hips ≤35 and >35 years of age with propensity matching were also performed. RESULTS: Patients who underwent acetabular microfracture were more likely to be male (81.8% vs 40.9%; P < .001), be older in age (35.0 vs 29.9 years; P = .001), have a higher body mass index (27.2 vs 25.0; P = .001), and have a greater alpha angle (69.6° vs 62.3°; P < .001) compared with the nonmicrofracture cohort (n = 533). After propensity matching to control for covariates, patients treated with microfracture displayed no differences in the modified Harris Hip Score or Hip Disability and Osteoarthritis Outcome Score (P = .22-.95) but were more likely to undergo total hip arthroplasty (THA) (13% [7/54] compared with 4% [6/162] in the control group; P = .002), and age >35 years was associated with conversion to THA after microfracture. Microfracture performed at or before 35 years of age portended good outcomes with no significant risk of conversion to THA at the most recent follow-up. CONCLUSION: Microfracture of acetabular cartilage defects appears to be safe and associated with reliably improved short- to mid-term results in younger patients; modified expectations should be realized when full-thickness chondral lesions are identified in patients >35 years of age.

Interdisciplinary strategies to prevent long-term and detrimental opioid use following trauma: a stakeholder consensus study.

OBJECTIVE: Prolonged opioid use is common following traumatic injuries. Although preventive strategies have been recommended, the evidence supporting their use is low. The objectives of this study were to select interdisciplinary strategies to prevent long-term, detrimental opioid use in trauma patients for further evaluation and to identify implementation considerations. DESIGN: A consensus study using the nominal group technique. SETTING: Four trauma systems in Canada. SUBJECTS: Participants included expert clinicians and decision makers, and people with lived experience. METHODS: Participants had to discuss the relevance and implementation of 15 strategies and then rank them using a 7-point Likert scale. Implementation considerations were identified through a synthesis of discussions. RESULTS: A total of 41 expert stakeholders formed the nominal groups. Overall, eight strategies were favored: 1) using multimodal approach for pain management, 2) professional follow-up in physical health, 3) assessment of risk factors for opioid misuse, 4) physical stimulation, 5) downward adjustment of opioids based on patient recovery, 6) educational intervention for patients, 7) training offered to professionals on how to prescribe opioids, and 8) optimizing communication between professionals working in different settings. Discussions with expert stakeholders revealed the rationale for the selected strategies and identified issues to consider when implementing them. CONCLUSION: This stakeholder consensus study identified, for further scientific study, a set of interdisciplinary strategies to promote appropriate opioid use following traumatic injuries. These strategies could ultimately decrease the burden associated with long-term opioid use.

Strategies to prevent long-term opioid use following trauma: a Canadian practice survey.

PURPOSE: To evaluate how Canadian clinicians involved in trauma patient care and prescribing opioids perceive the use and effectiveness of strategies to prevent long-term opioid therapy following trauma. Barriers and facilitators to the implementation of these strategies were also assessed. METHODS: We conducted a web-based cross-sectional survey. Potential participants were identified by trauma program managers and directors of the targeted departments in three Canadian provinces. We designed our questionnaire using standard health survey research methods. The questionnaire was administered between April 2021 and November 2021. RESULTS: Our response rate was 47% (350/744), and 52% (181/350) of participants completed the entire survey. Most respondents (71%, 129/181) worked in teaching hospitals. Multimodal analgesia (93%, 240/257), nonsteroidal anti-inflammatory agents (77%, 198/257), and physical stimulation (75%, 193/257) were the strategies perceived to be the most frequently used. Several preventive strategies were perceived to be very effective by over 80% of respondents. Of these, some that were reported as not being frequently used were perceived to be among the most effective ones, including guidelines or protocols, assessing risk factors for opioid misuse, physical health follow-up by a professional, training for clinicians, patient education, and prescription monitoring systems. Staff shortages, time constraints, and organizational practices were identified as the main barriers to the implementation of the highest ranked preventive strategies. CONCLUSIONS: Several strategies to prevent long-term opioid therapy following trauma are perceived as being effective by those prescribing opioids in this population. Some of these strategies appear to be commonly used in everyday practice and others less so. Future research should focus on which preventive strategies should be given higher priority for implementation before assessing their effectiveness.

RéSUMé: OBJECTIF: Évaluer comment les cliniciens canadiens impliqués dans les soins aux patients traumatisés et prescrivant des opioïdes perçoivent l'utilisation et l'efficacité des stratégies visant à prévenir le traitement prolongé par opioïde après un traumatisme. Les obstacles et facilitateurs de la mise en œuvre de ces stratégies ont aussi été analysés. MéTHODES: Nous avons réalisé une enquête transversale via le Web. Les participants potentiels ont été identifiés par les gestionnaires et directeurs de programmes de traumatologie des départements ciblés dans trois provinces canadiennes. Nous avons conçu notre questionnaire en utilisant la méthodologie de recherche usuelle des enquêtes de santé. Le questionnaire a été administré entre avril 2021 et novembre 2021. RéSULTATS: Notre taux de réponse a été de 47 % (350/744) et 52 % (181/350) des participants ont complété l'enquête dans sa totalité. La majorité des personnes interrogées (71 %, 129/181) travaillait dans des hôpitaux universitaires. L'analgésie multimodale (93 %, 240/257), les anti-inflammatoires non stéroïdiens (77 %, 198/257) et la stimulation physique (75 %, 193/257) étaient les stratégies perçues comme étant le plus fréquemment utilisées. Plusieurs stratégies préventives étaient perçues comme étant très efficaces par plus de 80 % des répondants. Parmi celles-ci, certaines étaient signalées comme n'étant pas utilisées très souvent, mais perçues comme étant les plus efficaces, notamment les lignes directrices et protocoles évaluant les facteurs de risque d'utilisation abusive des opioïdes, le suivi de la santé physique par un professionnel, la formation des cliniciens, l'éducation des patients et les systèmes de suivi des prescriptions. La pénurie de personnels, les contraintes de temps et les pratiques de l'établissement ont été identifiées comme étant les principaux obstacles à la mise en place des stratégies préventives classées parmi les premières. CONCLUSIONS: Plusieurs stratégies de prévention du traitement par opioïdes à long terme après un traumatisme sont perçues comme efficaces par ceux qui les prescrivent à cette population de patients. Certaines de ces stratégies apparaissent comme couramment utilisées dans la pratique quotidienne et d'autres moins souvent. La recherche future devrait se concentrer sur la détermination des stratégies préventives auxquelles il faudrait accorder la plus grande priorité de mise en œuvre avant d'évaluer leur efficacité.

Knee braces and foot orthoses multimodal treatment of medial knee osteoarthritis.

BACKGROUND: Knee braces and lateral wedge foot orthoses are two treatment options recommended for medial knee osteoarthritis, but the combination of both of them could further improve their effectiveness. RESEARCH QUESTION: The aim was to evaluate whether the combination of lateral wedge foot orthoses with two types of knee brace enhances the biomechanical effects and pain relief during the stance phase of gait while maintaining comfort. METHODS: Ten patients with medial knee osteoarthritis were fitted with a standard valgus brace, an unloader brace with valgus and external rotation functions, and 7° lateral wedge foot orthoses. The pain relief, comfort, kinematics and kinetics of the lower limb were measured during walking without orthotics, with the combined and with the isolated treatments. RESULTS: The valgus and external rotation brace significantly reduced the knee adduction moment and allowed more knee flexion both in isolation and in combination to foot orthoses compared to the valgus brace or without treatment. Pain relief was not significant with the different orthotic treatment modalities. The valgus brace and combined treatment with either brace significantly increased the discomfort level, whereas the valgus and external rotation brace or foot orthoses in isolation did not induce significant discomfort. SIGNIFICANCE: Amongst the tested orthotic treatment modalities, the valgus and external rotation brace obtained better biomechanical outcomes while maintaining comfort. The combined treatment with foot orthoses enhanced the effectiveness of the valgus brace, however foot orthoses may be unnecessary with the valgus and external rotation brace.

Continuous vs. single-shot adductor canal block for pain management following primary total knee arthroplasty: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Adductor canal block (ACB) provides effective analgesia following total knee arthroplasty (TKA). This systematic review aimed to compare continuous and single-shot ACB for pain management and functional recovery following TKA. METHODS: MEDLINE, Embase, Web of Science and CENTRAL were searched up to January 5th, 2021. Included studies were randomized controlled trials comparing continuous to single-shot ACB for postoperative pain management after primary TKA. Primary outcome was opioid consumption and secondary outcomes were pain intensity, quadriceps strength, mobility, complications, and length of hospital stay. Meta-analyses were performed using random-effects method. RESULTS: Eleven studies (910 patients) were included in this systematic review. Continuous ACB did not significantly decrease opioid consumption (8 studies; 642 patients; MD=-5.67; 95% CI: -13.87 to 2.54; I2=13%) but significantly decreased 48hours pain scores (10 studies; 852 patients; MD=-0,73; 95% CI: -0.93 to -0.54; I2=54%). Continuous ACB improved quadriceps strength (4 studies; 250 patients; SMD=0.59; 95% CI: 0.16 to 1.03; I2=63%) but not Timed Up and Go test performance (5 studies; 524 patients; MD=3.99; 95% CI: -8.98 to 1.01; I2=89%). Type of ACB did not affect nausea and vomiting (5 studies; 357 patients; RR=1.23; 95% CI: 0.65 to 2.34; I2=0%) nor length of hospital stay (8 studies; 655 patients; MD=-0.13; 95% CI: -0.28 to 0.01; I2=36%). CONCLUSION: Continuous ACB did not reduce opioid consumption following TKA. Larger trials are required.

Effect of Osteochondroplasty on Time to Reoperation After Arthroscopic Management of Femoroacetabular Impingement: Analysis of a Randomized Controlled Trial.

Background: A subset of patients with femoroacetabular impingement (FAI) fail arthroscopic management. It is not clear which patients will fail surgical management; however, several surgical and patient factors, such as type of procedure and age, are thought to be important predictors. Purpose: This time-to-event analysis with a 27-month follow-up analysis compared the effect of (1) arthroscopic osteochondroplasty with or without labral repair versus (2) arthroscopic lavage with or without labral repair on the time to reoperation in adults aged 18 to 50 years with FAI. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Eligible participants had been randomized in a previous study trial to a treatment of arthroscopic osteochondroplasty or arthroscopic lavage with or without labral repair. Using the comprehensive data set from the Multinational Femoroacetabular Impingement Randomized controlled Trial, all reoperations until 27 months after surgery were identified. The analysis was conducted using a Cox proportional hazards model, with percentage of patients with a reoperation evaluated in a time-to-event analysis as the outcome. The independent variable was the procedure, with age and impingement subtype explored as potential covariates. The effects from the Cox model were expressed as the hazard ratio (HR). All tests were 2-sided, with an alpha level of .05. Results: A total of 108 patients in the osteochondroplasty group and 106 patients in the lavage group were included. The mean age of the patients included in the study was 36 ± 8.5 years. Overall, 27 incident reoperations were identified within the 27-month follow-up, with an incidence rate of 6 per 100 person-years. Within the osteochondroplasty group, 8 incident reoperations were identified (incidence rate, 3.4 per 100 person-years), while within the lavage group, 19 incident reoperations were identified (incidence rate, 8.7 per 100 person-years). The hazard of reoperation for patients undergoing osteochondroplasty was 40% of that of patients undergoing lavage (HR, 0.40 [95% CI, 0.17-0.91] P = .029). Conclusion: This study demonstrated that for adults between the ages of 18 and 50 years with FAI, arthroscopic osteochondroplasty was associated with a 2.5-fold decrease in the hazard of reoperation at any point in time compared with arthroscopic lavage. Registration: NCT01623843 (ClinicalTrials.gov identifier).

The risk of venous thromboembolism in surgically treated hip fracture: A retrospective cohort study of 5184 patients.

INTRODUCTION: Elderly patients undergoing surgery for a hip fracture are at risk of venous thromboembolism (VTE). The known risk of VTE is low due to thromboprophylaxis (1.8-2.5% at three months). Most previous studies have ignored the high mortality in that population when calculating the risk of VTE. Hip fracture treatment has also evolved over the last decade. The real risk of VTE today is unknown. We asked what was the risk of symptomatic VTE following surgery for a hip fracture in an elderly population. We also asked what kind of bleeding events were associated with thromboprophylaxis. HYPOTHESIS: The risk of VTE will be lower than previously described due to modern postoperative care. PATIENTS AND METHODS: Retrospective cohort study of all patients≥65-years-old undergoing surgery for a hip fracture in two Canadian academic centers, between January 1, 2008, and January 1, 2019. Symptomatic VTE (pulmonary embolism or deep venous thrombosis) confirmed by imagery were assessed. The follow-up was fixed at 3 months. The cumulated risks of VTE and bleeding events were calculated using the Kaplan-Meier estimator and a logistic regression model was used to determine risk factors. RESULTS: The cohort included 5184 patients. The mean age was 83±8 years old and 76% of patients were female. In total, 98.8% of this cohort received postoperative thromboprophylaxis. Low-molecular-weight heparin was given for 35 days in 87% of this cohort. The risk of venous thromboembolism was 4.7±0.5% at 3 months (n=144). Chronic obstructive pulmonary disease (odds ratio 1.6 [1.0-2.4]) and the use of warfarin as extended thromboprophylaxis (odds ratio 2.1 [1.3-3.6]) were associated with venous thromboembolism. The risk of bleeding was 5.9% (n=179) at 3 months. In total, 78% (n=141) of bleeding events were hematomas, of which only 12% (n=16) needed reoperation. The use of direct oral anticoagulant was associated with an increased risk of bleeding events (odds ratio, 2.8 [1.5-5.0]). Mortality at 3 months was 8.4%. DISCUSSION: The risk of venous thromboembolism is higher than expected in a population treated for this condition (4.7% vs. 1.8-2.5% at 3 months as previously described). Bleeding events were mostly hematomas and few needed reoperations for wound complication. Future research should focus on the management of thromboprophylaxis in that population. LEVEL OF EVIDENCE: III; retrospective cohort study.

Return to Baseline Physical Activity After Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autografts for Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Bone-patellar tendon-bone (BPTB) and hamstring tendon (HT) autografts are the most utilized grafts for primary anterior cruciate ligament (ACL) reconstruction. The ability of a patient to return to a preinjury level of physical activity is a key consideration in choice of graft; the influence of graft choice on this metric lacks consensus in the literature. PURPOSE: To assess the effects of autograft choice (BPTB vs HT) for primary ACL reconstruction on return to baseline level of physical activity and/or sports participation. STUDY DESIGN: Meta-analysis; Level of evidence, 1. METHODS: A systematic review of randomized controlled trials comparing the use of BPTB and HT autografts for primary ACL reconstruction was conducted. The electronic databases EMBASE, MEDLINE, Cochrane CENTRAL, and Web of Science were comprehensively queried through September 23, 2019. The primary outcome was return to preinjury level of activity/sports. Secondary outcomes included knee stability testing (Lachman, KT-1000 arthrometer, and pivot-shift tests) and clinical subjective knee scores (Tegner, Cincinnati, International Knee Documentation Committee, and Lysholm). Two independent reviewers were involved in the screening of titles and abstracts, data extraction, and the assessment of risk of bias. Meta-analyses were performed respecting the Cochrane Handbook for Systematic Reviews of Intervention. RESULTS: A total of 29 studies (N = 3099 patients) were eligible for this review, of which 13 (n = 1029 patients) reported on return to baseline level of sports as an endpoint. The risk ratio (RR) of using BPTB vs HT on return to baseline sport level was 1.03 (0.91-1.17; P = .63). Absence of a positive pivot-shift test was the only secondary outcome, with a statistically significant RR of 0.66 (95% CI, 0.50-0.86) in favor of BPTB autografts (P = .002). CONCLUSION: In reviewing the current literature, no recommendation can be made on the optimal graft choice when using a return to baseline level of physical activity and/or sports participation as a primary metric.