Single-Shot Femoral Nerve Block Does Not Cause Long-Term Strength and Functional Deficits Following Anterior Cruciate Ligament Reconstruction.

PURPOSE: To determine if patients treated with a single-shot femoral nerve block have strength and functional deficits at 9-month follow-up. METHODS: Forty-three patients who underwent primary anterior cruciate ligament reconstructions were randomized to receive either a preoperative single-shot femoral nerve block or local infiltration anesthesia for primary pain control. All patients underwent a standardized comprehensive rehabilitation program postoperatively. Isokinetic strength and function was tested using a Biodex machine at 9 months or more postoperatively comparing the operative and nonoperative extremity. RESULTS: No significant difference in strength was found at an average of 10.6 months postoperatively (range, 9-15 months) between the femoral nerve block and control groups. In comparing strength deficits, we found no difference in slow isokinetic extension strength (22.4% vs 27.8%, P = .51), fast isokinetic extension strength (18.5% vs 12.5%, P = .41), slow isokinetic flexion strength (11.0% vs 15.1%, P = .55), and fast isokinetic flexion strength (8.2% vs 4.9%, P = .56) in the femoral nerve block versus control groups, respectively. In terms of functional outcomes, there also was no difference in deficits for single-leg hop distance (P = .12), timed single-leg hop (P = .74), and single-leg triple hop distance (P = .94). Maximal strength noted to be within 15% of the contralateral limb was achieved in 40% of patients and maximal function in 63% of patients at an average of 10.6 months postoperatively. A 13% complication rate was found in patients who received a femoral nerve block (1 with prolonged quadriceps inhibition and 2 with prolonged sensory disturbances). CONCLUSIONS: Our study found a 13% motor/sensory complication rate in patients who underwent femoral nerve block for pain control after anterior cruciate ligament reconstruction. Although these deficits may persist, they are not permanent and are not different when compared with controls at 9-month follow-up. However, maximal strength and function are not fully restored at normal return to play time and rehabilitation should continue long term to maximize recovery. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Liposomal Bupivacaine Versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial.

PURPOSE: To compare femoral nerve block (FNB) versus local liposomal bupivacaine (LB) for pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction. METHODS: Eighty-five patients undergoing primary ACL reconstruction were assessed for participation. We performed a prospective randomized trial in accordance with the CONSORT (Consolidated Standards of Reporting Trials) 2010 statement. The study arms included either intraoperative local infiltration of LB (20 mL of bupivacaine/10 mL of saline solution) or preoperative FNB with a primary outcome of postoperative pain levels (visual analog scale) for 4 days. Secondary outcomes assessed included opioid consumption (intravenous morphine equivalents), hours slept, patient satisfaction, and calls to the physician. Randomization was by a computerized algorithm. The observer was blinded and the patient was not blinded to the intervention. RESULTS: One patient declined participation; 2 patients were excluded after randomization. A total of 82 patients were analyzed. Outcomes showed a significant increase in pain in the LB group between 5 and 8 hours postoperatively (mean ± standard deviation, 6.3 ± 2.0 versus 4.8 ± 2.6; P = .01). There were no significant differences between the groups in mean daily pain levels, morphine equivalents, or patient satisfaction when we controlled for graft type, age, body mass index, and sex. Patients receiving an FNB had a nonsignificant increase in number of sleep disturbances on the day of surgery (mean ± standard deviation, 4.4 ± 3.7 v 3.1 ± 2.1; P = .09) and were more likely to call their doctor the following day because of pain (29% v 8%, P = .04). Six patients in the FNB group had either prolonged quadriceps inhibition or sensory disturbance. One patient in the LB group required reoperation for a flexion contracture. CONCLUSIONS: An increase in acute postoperative pain was found with LB compared with FNB for post-ACL reconstruction pain control. After the acute postoperative period, there were no significant differences in opioid consumption or pain control. The occurrence of nerve irritation postoperatively was found to be higher in the FNB group. LEVEL OF EVIDENCE: Level I, prospective randomized trial.

Major League Baseball pitch velocity and pitch type associated with risk of ulnar collateral ligament injury.

BACKGROUND: The number of Major League Baseball (MLB) pitchers requiring ulnar collateral ligament (UCL) reconstructions is increasing. Recent literature has attempted to correlate specific stresses placed on the throwing arm to risk for UCL injury, with limited results. METHODS: Eighty-three MLB pitchers who underwent primary UCL reconstruction were evaluated. Pitching velocity and percent of pitch type thrown (fastball, curve ball, slider, and change-up) were evaluated 2 years before and after surgery. Data were compared with control pitchers matched for age, position, size, innings pitched, and experience. RESULTS: The evaluation of pitch velocity compared with matched controls found no differences in pre-UCL reconstruction pitch velocities for fastballs (91.5 vs. 91.2 miles per hour [mph], P = .69), curveballs (78.2 vs. 77.9 mph, P = .92), sliders (83.3 vs. 83.5 mph, P = .88), or change-ups (83.9 vs. 83.8 mph, P = .96). When the percentage of pitches thrown was evaluated, UCL reconstructed pitchers pitch significantly more fastballs than controls (46.7% vs. 39.4%, P = .035). This correlated to a 2% increase in risk for UCL injury for every 1% increase in fastballs thrown. Pitching more than 48% fastballs was a significant predictor of UCL injury, because pitchers over this threshold required reconstruction (P = .006). CONCLUSION: MLB pitchers requiring UCL reconstruction do not pitch at higher velocities than matched controls, and pitch velocity does not appear to be a risk factor for UCL reconstruction. However, MLB pitchers who pitch a high percentage of fastballs may be at increased risk for UCL injury because pitching a higher percent of fastballs appears to be a risk factor for UCL reconstruction.

The Use of Trabecular Metal Cones in Complex Primary and Revision Total Knee Arthroplasty.

Trabecular metal cones are one option for treating osseous defects during TKA. A total of 83 consecutive TKAs utilizing cones with an average of 40 months follow-up were reviewed. There were 24 males and 59 females, with an average age of 69 years old. Four were complex primary and 79 were revision procedures. Of 83 patients, 10 (12%) required repeat revision surgery (8 infections, one periprosthetic fracture, one aseptic loosening) and overall, 37 of 83 patients (45%) experienced at least one complication. Of 73 unrevised knees, 72 (99%) demonstrated radiographic evidence of osseointegration. Despite a high complication rate in this population, trabecular metal cones represent an attractive option for managing bone loss in complex primary and revision TKA with a high rate of osseointegration.

Does Hospital Consumer Assessment of Healthcare Providers and Systems survey correlate with traditional metrics of patient satisfaction? The challenge of measuring patient pain control and satisfaction in total joint replacement.

BACKGROUND: Medicare reimbursements have been tied to patient satisfaction measures. Despite these measures' influence on reimbursements, the relationship between pain management and patient satisfaction remains unclear. This study aims to evaluate the relationship between traditional patient perception of pain control and their overall satisfaction after joint replacement. METHODS: This study is a retrospective review of consecutive primary total hip and total knee replacements. A total of 286 patients who underwent primary total hip (N = 106) and total knee (N = 196) replacements with completed Hospital Consumer Assessment of Healthcare Providers and Systems surveys were evaluated. Pain control, communication, and hospital satisfaction were stratified into satisfactory or unsatisfactory groups. These 2 groups were compared in terms of visual analog scale (VAS), opioid use in morphine equivalents, length of hospital stay, anesthesia type, and demographics. RESULTS: Average VAS and opioid use did not differ between patient groups for any of the questions evaluated. Those who responded "always" to pain domain questions had a statistically shorter length of stay compared to patients with other response. On average, those who endorsed "always" on communication question were younger. CONCLUSIONS: Patients who endorsed satisfactory pain control and communication with staff had shorter lengths of stay. There was no relationship between survey scores and traditional pain control measures such as VAS and opioid use. This questions the relevance of our primary pain measures in assessing patient perception of pain control. Length of stay may be a better surrogate marker for patient satisfaction of pain control.

Facet Sparing Foraminal Decompression Using the Flexible Shaver Foraminotomy System: Nerve Safety, Pain Relief, and Patient Satisfaction.

BACKGROUND: A number of surgical options exist for decompressing lumbar foraminal stenosis. Flexible shaver foraminotomy is a recent addition to this armamentarium. While the foraminotomy device has been incorporated into clinical practice, the literature on its safety and efficacy remain limited. We aimed to evaluate nerve safety, pain relief, and patient satisfaction in a series of patients treated with the iO-Flex shaver system (Amendia, Inc., Marietta, Georgia). METHODS: Thirty-one consecutive patients with lumbar foraminal stenosis underwent foraminal decompression using the flexible microblade shaver system at 62 neuroforamina. The shavers were inserted into each foramen using an open hemilaminotomy and fluoroscopic guidance. Nerve mapping via mechanomyography (MMG) was used to ensure nerve safety. Perioperative charts were reviewed to find the incidence of neurologic complications and to quantify pain relief. Average office-based follow-up was 5.3 months. A 3-item questionnaire was administered to assess patient satisfaction during late follow-up, which occurred at an average of 21 months. RESULTS: No planned iO-Flex foraminotomies were aborted. Neurologic complications included transient dysesthetic pain in 1 patient (3.2%, n = 31), and transient numbness in 3 patients (9.7%, n = 31). There were no motor deficits. The composite nerve complication rate was 12.7%. Preoperative visual analog scale scores decreased from a mean of 7.1 (n = 31, standard deviation [SD] 2.0) to a mean of 3.5 (n = 30, SD 2.5). If asked to repeat their decision to do surgery, 81% of patients would redo the procedure. The rate of patient dissatisfaction was 19%. CONCLUSIONS: Decompression of lumbar foramina using the flexible shaver system and MMG nerve mapping is safe and effective, although the short-term sensory complication with this technique may be higher than previously reported. Patient satisfaction with iO-Flex foraminotomy is comparable to reported satisfaction outcomes for traditional lumbar decompression. LEVEL OF EVIDENCE: 4.

Pain Assessment After Anterior Cruciate Ligament Reconstruction: Bone-Patellar Tendon-Bone Versus Hamstring Tendon Autograft.

BACKGROUND: Anterior cruciate ligament (ACL) reconstruction is a common outpatient procedure that is accompanied by significant postoperative pain. PURPOSE: To determine differences in acute pain levels between patients undergoing ACL reconstruction with bone-patellar tendon-bone (BTB) versus hamstring tendon (HS) autograft. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 70 patients who underwent primary ACL reconstruction using either BTB or HS autografts consented to participate. The primary outcome of the study was postoperative pain levels (visual analog scale), which were collected immediately after surgery and for 3 days postoperatively. Secondary outcome measures included opioid consumption (intravenous morphine equivalents), hours slept, patient satisfaction, reported breakthrough pain, and calls to the physician. RESULTS: Patients treated with BTB had increased pain when compared with those treated with HS in the acute postoperative period (mean ± SD: day 0, 6.0 ± 1.7 vs 5.2 ± 2.0 [P = .066]; day 1, 5.9 ± 1.7 vs 4.9 ±1.7 [P = .024]; day 2, 5.2 ± 1.9 vs 4.1 ± 2.0 [P = .032]; day 3, 4.8 ± 2.1 vs 3.9 ± 2.3 [P = .151]). There were also significant increases in reported breakthrough pain (day 0, 76% vs 43% [P = .009]; day 1, 64% vs 35% [P = .003]) and calls to the physician due to pain (day 1, 19% vs 0% [P = .041]) in the BTB group. There were no significant differences in narcotic requirements or sleep disturbances. Overall, the BTB group reported significantly less satisfaction with pain management on days 0 and 1 (P = .024 and .027, respectively). CONCLUSION: A significant increase in acute postoperative pain was found when performing ACL reconstruction with BTB compared with HS. Patients treated with BTB were more likely to have breakthrough pain, decreased satisfaction with their pain management, and to contact their physician due to pain. These findings suggest a difference in early postoperative pain between the 2 most common graft options for ACL reconstruction. Patients should be informed of the differences in acute postoperative pain when deciding on graft choice with their physician.