RESUMO
INTRODUCTION: Successful outpatient anterior cruciate ligament (ACL) reconstruction hinges on effective analgesia. Routinely, oral narcotic agents have been the preferred analgesic postoperatively in orthopaedic surgery. However, these agents have several known adverse effects and are associated with a potential for abuse. This study evaluates the efficacy of ketorolac, a nonsteroidal anti-inflammatory drug with analgesic properties, as an adjuvant agent for postoperative pain control after ACL reconstruction. METHODS: Adult patients undergoing primary ACL reconstruction were prospectively enrolled. Exclusion criteria involved patients with a history of bleeding diathesis, renal dysfunction, chronic analgesia use, or alcohol abuse. Eligible patients were randomized into one of two groups. The control group received a standard-of-care pain protocol involving oxycodone-acetaminophen 5 to 325 on discharge. The ketorolac group additionally received intravenous ketorolac postoperatively and 3 days of oral ketorolac on discharge. Pain levels and total narcotic utilization were recorded three times per day for the first 5 days after surgery. Pain and functional outcomes were obtained at 2 and 6 weeks postoperatively. RESULTS: The final analysis included 48 patients; the mean age of the cohort was 32 ± 11.6 years, and 60.4% of patients were female. No differences were observed in preoperative demographics, comorbidities, and preoperative functional scores between the two groups. Over the first 5 days after surgery, patients in the ketorolac group consumed a mean of 45.4% fewer narcotic pills than the control group (P < 0.001). In addition, mean postoperative pain scores were 22.36 points lower for patients in the ketorolac group (P < 0.001). There was no difference in functional outcome scores at up to 6 weeks postoperatively or adverse events between the two groups with no reported cases of gastrointestinal bleeding. DISCUSSION: The use of adjunctive intravenous and short-term oral ketorolac substantially reduces narcotic utilization and pain levels after ACL reconstruction. CLINICALTRIALGOV REGISTRATION NUMBER: NCT04246554.
Assuntos
Reconstrução do Ligamento Cruzado Anterior , Cetorolaco , Humanos , Feminino , Adulto Jovem , Adulto , Masculino , Estudos Prospectivos , Cetorolaco/uso terapêutico , Projetos de Pesquisa , Reconstrução do Ligamento Cruzado Anterior/efeitos adversos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/etiologiaRESUMO
Recently, there has been much interest in anatomic double-bundle reconstruction of the anterior cruciate ligament (ACL). Double-bundle reconstruction of the ACL requires adequate footprint size to place two femoral tunnels. The purpose of this study was to determine if there is a correlation between lateral intercondylar ridge length and gender and/ or height. We measured the femoral attachment of the ACL to determine if patient sex and/or height could be used to predict ACL femoral footprint size. We measured the length of the lateral intercondylar ridge in 65 skeletally mature human femora. Gender and height was recorded for each individual. We used bivariate regression analysis to determine correlations between both height and gender and the length of the lateral intercondylar ridge. The principal findings of our study demonstrate that there is no correlation between ACL femoral footprint size and gender or footprint size and height. Our study demonstrates that patient height and gender cannot be used for preoperative planning when deciding whether a given patient has adequate footprint size to support double-bundle reconstruction of the ACL.
Assuntos
Ligamento Cruzado Anterior/anatomia & histologia , Estatura , Caracteres Sexuais , Adulto , Feminino , Fêmur/anatomia & histologia , Humanos , Masculino , Análise de RegressãoRESUMO
PURPOSE: The purpose of this study was to determine whether posterolateral rim morphology can be delineated on plain radiographic images. METHODS: We obtained 20 femora from the Cleveland Museum of Natural History (10 each with distinct and indistinct posterolateral rims). Four blinded reviewers evaluated radiographic posterolateral rim morphology on lateral radiographs. The reviewers included a musculoskeletal radiologist, a fellowship-trained sports medicine surgeon, a pediatric orthopaedic surgeon, and a junior orthopaedic resident. Interobserver and intraobserver reliability was determined. RESULTS: Radiographically, posterolateral rim morphology was classified into 2 types. Type 1 rims have a defined transition from Blumensaat's line to the posterior femoral cortex. Type 2 rims have an indistinct transition. Interobserver reliability showed substantial agreement during the first (kappa = 0.65) and second (kappa = 0.70) sessions. Intraobserver reliability was nearly perfect, with kappa values ranging from 0.8 to 1.0. CONCLUSIONS: It has been shown anatomically that the posterolateral rim has variable morphology. We have shown that posterolateral rim morphology can be delineated on lateral plain film images. Radiographic type 1 rims correlate with distinct posterolateral rim morphology. Radiographic type 2 rims correlate with indistinct posterolateral rim morphology. CLINICAL RELEVANCE: For surgeons who reference the posterolateral rim for femoral tunnel placement during anterior cruciate ligament reconstruction, indistinct posterolateral rim morphology may result in errant tunnel placement. Improved awareness of posterolateral rim morphology preoperatively may help avoid technical errors with placement of the femoral tunnel.
Assuntos
Ligamento Cruzado Anterior/diagnóstico por imagem , Fêmur/anatomia & histologia , Fêmur/diagnóstico por imagem , Ligamento Cruzado Anterior/anatomia & histologia , Ligamento Cruzado Anterior/cirurgia , Artroscopia/métodos , Cabeça do Fêmur/diagnóstico por imagem , Colo do Fêmur/diagnóstico por imagem , Humanos , Músculo Esquelético/diagnóstico por imagem , Radiografia , Procedimentos de Cirurgia Plástica , Tíbia/anatomia & histologiaRESUMO
BACKGROUND: Anterior cruciate ligament reconstructions in skeletally immature patients are becoming more commonplace. Complications of growth disturbance remain a major concern, especially at the distal femoral physis, and are often attributed to technical errors. A review of the literature revealed limited anatomical data of the skeletally immature intercondylar notch to guide surgical technique. METHODS: We studied 103 preserved femora aged 3 to 20 years, with 33 of these aged 7 to 15 years. The distance between the "resident's ridge" (lateral intercondylar ridge) and the "over-the-top" position (OTP) was measured at the 11-, 10-, and 9-o'clock positions in the right femora, and the 1-, 2-, and 3-o'clock positions in the left femora. The angles between the femoral surface, distal femoral physis, and femoral shaft were measured in the coronal and sagittal planes using a goniometer. RESULTS: Femora in the 13- to 15-year-old subgroup tended to have a more clearly defined resident's ridge than femora in the younger subgroups. The space between resident's ridge and the OTP was on average greater than 8 mm at all 3 positions in the 13- to 15-year-old subgroup, and greater than 7 mm at all 3 positions in the 10- to 12-year-old subgroup, with more space available with a more peripheral starting point. The average angles between the femoral surface and physis in the sagittal and coronal planes were 47 degrees and 36 degrees in the 13- to 15-year-old subgroup, and 58 degrees and 28 degrees in the 10- to 12-year-old subgroup. The average angles between the distal femoral shaft and physis in the sagittal and coronal planes were -9 degrees and 7 degrees in the 13- to 15-year-old subgroup, and -6 degrees and 7 degrees in the 10- to 12-year-old subgroup. Analysis of females versus males demonstrated larger distances between resident's ridge and the OTP in males, but no differences in the angular measurements. CONCLUSIONS: In younger patients, the resident's ridge is less commonly present and less clearly defined. The femoral tunnel can usually be drilled behind the resident's ridge at the 11-o'clock/1-o'clock position, although in females, the ridge is more likely to be included in the drill hole. In both males and females, the tunnel should be aimed posterior and medial with respect to the perpendicular of the femoral surface and anterior and medial with respect to the shaft to drill through the physis with less obliquity, and to provide a tunnel deep enough to avoid spanning the physis with bone or hardware.
Assuntos
Ligamento Cruzado Anterior/anatomia & histologia , Fêmur/anatomia & histologia , Adolescente , Adulto , Fatores Etários , Pesos e Medidas Corporais , Cadáver , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Fatores SexuaisRESUMO
BACKGROUND: During anterior cruciate ligament reconstruction, proper femoral tunnel placement is important. The purpose of the present study was to characterize the osseous anatomy of the femoral intercondylar notch. METHODS: We studied the morphology of the femoral intercondylar notch in 200 human femora from skeletally mature donors, with specific attention being paid to the morphology of the ridge on the lateral wall of the intercondylar notch and the posterolateral rim of the intercondylar notch. The distances from the posterolateral rim of the intercondylar notch to the lateral intercondylar ridge and from the posterolateral rim of the intercondylar notch to the inlet of the intercondylar notch (notch depth) were measured at the nine, ten, and eleven o'clock positions for right knees and at the one, two and three o'clock positions for left knees. RESULTS: The lateral intercondylar ridge was present in 194 femora and absent in six. The mean distance from the posterolateral rim of the intercondylar notch to the lateral intercondylar ridge was 9.0, 11.0, and 12.7 mm at the nine, ten, and eleven o'clock positions in right knees and the one, two, and three o'clock positions in left knees, respectively. We observed three different types of morphology of the posterolateral rim of the intercondylar notch. The morphology of the posterolateral rim of the intercondylar notch was distinct in 183 of 200 specimens. A distinct, straight border (type 1) was seen in 175 femora (87.5%); a distinct, V-shaped border (type 2) was seen in eight (4%); and an indistinct border (type 3) was seen in seventeen (8.5%). CONCLUSIONS: The morphology of the femoral intercondylar notch varies little. Occasionally, the posterolateral rim of the intercondylar notch is not well-defined. In these knees, accurate placement of commercial femoral tunnel aiming guides may be difficult.