Reducing rebound pain severity after arthroscopic shoulder surgery under general anesthesia and interscalene block: a two-centre randomized controlled trial of pre-emptive opioid treatment compared with placebo.

PURPOSE: Although a single-injection interscalene block provides effective early postoperative analgesia following shoulder surgery, patients may experience "rebound pain" when the block resolves. Our objective was to determine if oral hydromorphone (2 mg) given six hours after a single-injection interscalene block for arthroscopic shoulder surgery leads to a clinically significant reduction in the severity of rebound pain. METHODS: After approval from research ethics boards, we conducted a two-centre, parallel-group, double-blind, randomized, placebo-controlled superiority trial. Patients received preoperative interscalene block, general anesthesia, and either hydromorphone or placebo six hours after the block. The primary outcome was the worst pain score in the first 24 hr postoperatively, measured on an 11-point (0-10) numerical rating scale. RESULTS: A total of 73 participants were randomly assigned to either the hydromorphone or placebo group. There was no statistically significant difference in the mean (standard deviation) worst pain score within 24 hr between the hydromorphone and placebo groups (6.5 [2.4] vs 5.9 [2.3]; mean difference, 0.6; 95% confidence interval, -0.5 to 1.8). Similarly, we did not find any significant difference in the pain trajectory, opioid use, or incidence of nausea and vomiting between the groups. The mean time to worst pain was 14.6 hr, and the mean time to first rescue analgesia was 11.3 hr after interscalene block. CONCLUSION: Hydromorphone 2 mg given six hours after interscalene block did not reduce the severity of rebound pain postoperatively compared with placebo in patients undergoing arthroscopic shoulder surgery. STUDY REGISTRATION: ClinicalTrials.gov (NCT02939209); registered 19 October 2016.

RéSUMé: OBJECTIF: Bien qu'un bloc interscalénique à injection unique fournisse une analgésie postopératoire précoce efficace après une chirurgie de l'épaule, les patient·es peuvent ressentir une « douleur de rebond ¼ lorsque le bloc se résorbe. Notre objectif était de déterminer si l'hydromorphone orale (2 mg) administrée six heures après une injection unique de bloc interscalénique pour une chirurgie arthroscopique de l'épaule entraînait une réduction cliniquement significative de la gravité de la douleur de rebond. MéTHODE: Après l'approbation des comités d'éthique de la recherche, nous avons mené une étude de supériorité dans deux centres, en groupes parallèles, à double insu, randomisée et contrôlée par placebo. Les patient·es ont reçu un bloc interscalénique préopératoire, une anesthésie générale et de l'hydromorphone ou un placebo six heures après le bloc. Le critère d'évaluation principal était le pire score de douleur au cours des premières 24 heures postopératoires, mesuré sur une échelle d'évaluation numérique de 11 points (0 à 10). RéSULTATS: Au total, 73 personnes ont participé à l'étude et ont été aléatoirement assignées au groupe hydromorphone ou au groupe placebo. Il n'y avait pas de différence statistiquement significative dans le score moyen (écart type) de la pire douleur dans les 24 heures entre les groupes hydromorphone et placebo (6,5 [2,4] vs 5,9 [2,3]; différence moyenne, 0,6; intervalle de confiance à 95 %, −0,5 à 1,8). De même, nous n'avons trouvé aucune différence significative dans la trajectoire de la douleur, la consommation d'opioïdes ou l'incidence de nausées et vomissements entre les groupes. Le temps moyen jusqu'à la pire douleur était de 14,6 heures, et le temps moyen jusqu'à la première analgésie de secours était de 11,3 heures après le bloc interscalénique. CONCLUSION: L'hydromorphone 2 mg administrée six heures après le bloc interscalénique n'a pas réduit la gravité de la douleur de rebond postopératoire par rapport au placebo chez les patient·es bénéficiant d'une chirurgie arthroscopique de l'épaule. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT02939209); enregistrée le 19 octobre 2016.

Video-based assessment (VBA) of an open, simulated orthopedic surgical procedure: a pilot study using a single-angle camera to assess surgical skill and decision making.

BACKGROUND: Videos have been used in many settings including medical simulation. Limited information currently exists on video-based assessment in surgical training. Effective assessment tools have substantial impact on the future of training. The objectives of this study were as follows: to evaluate the inter-rater reliability of video-based assessment of orthopedic surgery residents performing open cadaveric simulation procedures and to explore the benefits and limitations of video-based assessment. METHODS: A multi-method technique was used. In the quantitative portion, four residents participated in a Surgical Objective Structured Clinical Examination in 2017 at a quaternary care training center. A single camera bird's-eye view was used to videotape the procedures. Five orthopedic surgeons evaluated the surgical videos using the Ottawa Surgical Competency Operating Room Evaluation. Interclass correlation coefficient was used to calculate inter-rater reliability. In the qualitative section, semi-structured interviews were used to explore the perceived strengths and limitations of video-based assessment. RESULTS AND DISCUSSION: The scores using video-based assessment demonstrated good inter-rater reliability (ICC = 0.832, p = 0.014) in assessing open orthopedic procedures on cadavers. Qualitatively, the strengths of video-based assessment in this study are its ability to assess global performance and/or specific skills, ability to reassess missed points during live assessment, and potential use for less common procedures. It also allows for detailed constructive feedback, flexible assessment time, anonymous assessment, multiple assessors and serves as a good coaching tool. The main limitations of video-based assessment are poor audio-video quality, and questionable feasibility for assessing readiness for practice. CONCLUSION: Video-based assessment is a potential adjunct to live assessment in orthopedic open procedures with good inter-rater reliability. Improving audio-video quality will enhance the quality of the assessment and improve the effectiveness of using this tool in surgical training.

Dual mini-fragment plate fixation of midshaft clavicle fractures is biomechanically equivalent to anatomic pre-contoured plating.

OBJECTIVES: To biomechanically compare the stiffness of midshaft synthetic clavicle osteotomies fixed with either superior anatomic pre-contoured locking plates, anterior anatomic pre-contoured locking plates, or short-segment dual orthogonal mini-plate fixation. DESIGN AND SETTING: Controlled laboratory study. Specimens Twenty-one synthetic pre-osteotomized clavicles were separated into three groups: superior plating, anterior plating, or dual-plating. Each clavicle was sequentially tested in non-destructive cycles of axial compression, three-point bending, and torsion. Load and displacement were recorded. Stiffness was calculated. RESULTS: No statistically significant differences were found between construct stiffness during axial compression, three-point bending, or torsional testing. One superior plated clavicle suffered catastrophic failure during axial compression. One dual mini-fragment plated clavicle suffered catastrophic failure during torsion. CONCLUSIONS: Orthogonal dual mini-fragment fixation of transverse clavicle fractures is biomechanically similar to superior and anterior pre-contoured anatomic locking plate fixation. No statistically significant differences in construct stiffness were found in axial compression, three-point bending, or torsion testing. Further clinical research is required to determine the long-term stability of dual mini-fragment plate fixation. LEVEL OF EVIDENCE: IV.

Cannabis use patterns among patients with upper extremity conditions at the time of legalization in Canada.

BACKGROUND: Recreational cannabis use was legalized in Canada in 2018. Cannabis use patterns and patient attitudes toward cannabis use, particularly in the context of these legal changes, are not well understood. Our aim was to evaluate baseline cannabis use patterns and attitudes at the time of legalization among patients with upper extremity conditions in Canada. METHODS: In 2018, we conducted a multicentre cross-sectional survey study of 1561 patients with upper extremity conditions at 7 surgical centres. Participants were asked whether they currently use cannabis. If yes, they were asked questions regarding usage patterns and perceptions of cannabis use, including likelihood of use, safety and comfort discussing it with their physician. RESULTS: In the 6 months after legalization, 790 (51%) participants felt that cannabis was safer than prescription narcotics, with 450 (29%) currently using cannabis. Reasons for cannabis use included pain (56%), stress (51%) and recreation (42%). Of the 1105 patients not using cannabis, 267 (24%) were more likely to consider it after legalization. Of the 450 cannabis users, 73 (16%) had been using it for less than 6 months, 206 (46%) stated they were more comfortable discussing cannabis with their physician after legalization and 195 (43%) were using cannabis more than 4 times per week. CONCLUSION: Many patients with upper extremity conditions were regularly using cannabis. Patients were more comfortable discussing cannabis with their physician than before legalization. Treating surgeons should be aware of these trends and expect to receive questions regarding cannabis use.