Intraoperative Ketamine in Total Knee Arthroplasty Does Not Decrease Pain and Narcotic Consumption: A Prospective Randomized Controlled Trial.

BACKGROUND: Multiple studies have demonstrated that ketamine, a glutamate receptor blocker, may decrease postoperative pain in abdominal and orthopedic surgeries. However, its role with spinal anesthesia and total knee arthroplasty (TKA) remains unknown. The purpose of this study is to determine the efficacy of subanesthetic dosing of ketamine during TKA on postoperative pain and narcotic consumption. METHODS: In this prospective, randomized, double-blinded clinical trial, we enrolled 91 patients undergoing primary TKA with spinal anesthesia in a single institution from 2017 to 2018. Patients were randomized to receive intraoperative ketamine infusion at a rate of 6 mcg/kg/min for 75 minutes or a saline placebo. All patients received spinal anesthesia and otherwise identical surgical approaches, pain management, and rehabilitation protocols. Patient-reported visual analog pain scores were calculated preoperatively, postoperative days (POD) 0-7, and 2 weeks. Narcotic consumption was evaluated on POD 0 and 1. RESULTS: There was no difference in average pain between ketamine and placebo at all time points except for at PODs 1 (45 vs 56, P = .041) and 4 (39 vs 49, P = .040). For least pain experienced, patients administered with ketamine experienced a reduction in pain only at POD 4 (22 vs 35, P = .011). There was no difference in maximum pain cohorts at all time points of the study or in-hospital morphine equivalents between the 2 cohorts. CONCLUSION: As part of multimodal pain management protocol, intraoperative ketamine does not result in a clinically significant improvement in pain and narcotic consumption following TKA.

Return to recreational sports participation following rotator cuff repair in adults over 40 Years of age: outcomes and return to play analysis.

Background: Despite the high prevalence of rotator cuff (RTC) tears in older adults, there is limited literature evaluating the return to recreational sport after repair. The purpose of this study was (1) to assess the patient-reported outcomes and return to sport rates following rotator cuff repair in patients aged more than 40 years with minimum 2-year follow-up; (2) to compare baseline, preoperative and postoperative outcomes, and level of play following repair of self-reported athletes with nonathletes; and (3) to compare return to sport rates in overhead athletes compared to nonoverhead athletes. Methods: Patients undergoing arthroscopic rotator cuff repair between January 2016 and January 2019 were screened for inclusion. Inclusion criteria included (1) age more than 40 years at the time of surgery, (2) arthroscopic repair of a full thickness RTC tear, and (3) preoperative American Shoulder and Elbow Surgeons score (ASES) available. Eligible patients were contacted and invited to fill out a custom return to sport and patient-reported outcome survey. Results: Overall, 375 of the 1141 eligible patients completed the survey instrument. There were 210 self-reported athletes (mean age 59.2 ± 9.55 years) and 165 nonathletes (mean age 62.0 ± 8.27 years) (P = .003). Of the athletes, 193 (91.9%) returned to sport. The average age of athletes was 59.4 ± 9.33 years for those who returned to sport and 57.9 ± 12.0 years for those who did not (P = .631). Athletes reported higher ASES scores than nonathletes both preoperatively (49.8 ± 20.3 vs. 44.8 ± 18.9, P = .015) and postoperatively (87.6 ± 16.7 vs. 84.9 ± 17.5, P = .036), but there was no difference in mean ASES improvement between groups (37.7 ± 23.0 vs. 40.3 ± 24.5, P = .307). There was no difference in postoperative Single Assessment Numeric Evaluation scores when comparing self-reported athletes to nonathletes (85.4 ± 17.5 vs. 85.0 ± 18.7, P = .836). After controlling for age, sex, body mass index, and smoking status using a multivariate analysis, there was no difference in mean ASES improvement when comparing athletes to nonathletes. Conclusion: There is a high rate of return to sport activities (> 90%) in older adult recreational athletes following arthroscopic repair of full thickness RTC tears and rates of return to sport did not significantly differ for overhead and nonoverhead athletes. Self-reported athletes were noted to have higher baseline, preoperative, and postoperative ASES scores than nonathletes, but the mean ASES improvement following repair did not significantly differ between groups.

Use of Triggers to Detect Adverse Events After Outpatient Orthopedic Surgery at a Single Ambulatory Surgery Center.

Literature on adverse events (AEs) after outpatient orthopedic surgery is relatively sparse, and efforts to detect, measure, and track AEs after outpatient surgery lag behind those for the inpatient setting. Detection of AEs has traditionally relied on patient safety indicators (from billing data) and self-reporting, but these methods have been shown to have low sensitivity, missing up to 90% of AEs. There is growing recognition that the trigger method, which uses "triggers" as red flags to initiate more detailed chart audits, can serve as a more sensitive alternative to detect AEs. Moreover, the recent widespread adoption of electronic health records (EHRs) can provide faster automated methods for identifying triggers and estimating AE rates. This study evaluates the ability of 6 separate EHR-based triggers to predict AEs after outpatient orthopedic surgery and compares this trigger method with AE self-reporting. Triggers have the potential to decrease postoperative morbidity after outpatient orthopedic surgery and may lead to quality improvement. Further research is needed to qualify triggers as screening tools in the outpatient setting. [Orthopedics. 2022;45(2):116-121.].

Radiologic Measurements in the Assessment of Patellar Instability: A Systematic Review and Meta-analysis.

BACKGROUND: Numerous diagnostic imaging measurements related to patellar instability have been evaluated in the literature; however, little has been done to compare these findings across multiple studies. PURPOSE: To review the different imaging measurements used to evaluate patellar instability and to assess the prevalence of each measure and its utility in predicting instability. We focused on reliability across imaging modalities and between patients with and without patellar instability. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: We performed a systematic review of the literature using the PubMed, SCOPUS, and Cochrane databases. Each database was searched for variations of the terms "patellar instability," "patellar dislocation," "trochlear dysplasia," "radiographic measures," "computed tomography," and "magnetic resonance imaging." Studies were included if they were published after May 1, 2009, and before May 1, 2019. A meta-analysis using a random effects model was performed on several measurements, comparing instability and control groups to generate pooled values. RESULTS: A total of 813 articles were identified, and 96 articles comprising 7912 patients and 106 unique metrics were included in the analysis. The mean patient age was 23.1 years (95% CI, 21.1-24.5), and 41% were male. The tibial tubercle-trochlear groove (TT-TG) distance was the most frequently included metric (59 studies), followed by the Insall-Salvati ratio and Caton-Deschamps index (both 26 studies). The interobserver intraclass correlation coefficients were excellent or good for the TT-TG distance and Insall-Salvati ratio in 100% of studies reporting them; however, for the Caton-Deschamps index and Blackburne-Peel ratio, they were excellent or good in only 43% and 40% of studies. Pooled magnetic resonance imaging values for TT-TG distance (P < .01), Insall-Salvati ratio (P = .01), and femoral sulcus angle (P = .02) were significantly different between the instability and control groups. Values for tibial tubercle-posterior cruciate ligament distance (P = .36) and Caton-Deschamps index (P = .09) were not significantly different between groups. CONCLUSION: The most commonly reported measurements for evaluating patellar instability assessed patellar tracking and trochlear morphology. The TT-TG distance was the most common measurement and was greater in the patellar instability group as compared with the control group. In addition, the TT-TG, tibial tubercle-posterior cruciate ligament, and patellar tendon-trochlear groove distances were highly reproducible measurements for patellar tracking, and the Insall-Salvati ratio had superior reproducibility for assessing patellar height.