Combined Dexamethasone and Dexmedetomidine as Adjuncts to Popliteal and Saphenous Nerve Blocks in Patients Undergoing Surgery of the Foot or Ankle: A Randomized, Blinded, Placebo-controlled Clinical Trial.

BACKGROUND: Both dexamethasone and dexmedetomidine increase the duration of analgesia of peripheral nerve blocks. The authors hypothesized that combined intravenous dexamethasone and intravenous dexmedetomidine would result in a greater duration of analgesia when compared with intravenous dexamethasone alone and placebo. METHODS: The authors randomly allocated participants undergoing surgery of the foot or ankle under general anesthesia and with a combined popliteal (sciatic) and saphenous nerve block to a combination of 12 mg dexamethasone and 1 µg/kg dexmedetomidine, 12 mg dexamethasone, or placebo (saline). The primary outcome was the duration of analgesia measured as the time from block performance until the first sensation of pain in the surgical area as reported by the participant. The authors predefined a 33% difference in the duration of analgesia as clinically relevant. RESULTS: A total of 120 participants from two centers were randomized and 119 analyzed for the primary outcome. The median [interquartile range] duration of analgesia was 1,572 min [1,259 to 1,715] with combined dexamethasone and dexmedetomidine, 1,400 min [1,133 to 1,750] with dexamethasone alone, and 870 min [748 to 1,138] with placebo. Compared with placebo, the duration was greater with combined dexamethasone and dexmedetomidine (difference, 564 min; 98.33% CI, 301 to 794; P < 0.001) and with dexamethasone (difference, 489 min; 98.33% CI, 265 to 706; P < 0.001). The prolongations exceeded the authors' predefined clinically relevant difference. The duration was similar when combined dexamethasone and dexmedetomidine was compared with dexamethasone alone (difference, 61 min; 98.33% CI, -222 to 331; P = 0.614). CONCLUSIONS: Dexamethasone with or without dexmedetomidine increased the duration of analgesia in patients undergoing surgery of the foot or ankle with a popliteal (sciatic) and saphenous nerve block. Combined dexamethasone and dexmedetomidine did not increase the duration of analgesia when compared with dexamethasone.

1.7 cm elongated Achilles tendon did not alter walking gait kinematics 4.5 years after non-surgical treatment.

PURPOSE: The aim of the present study was to evaluate Achilles tendon length after non-surgical treatment of acute Achilles tendon rupture (aATR), and to evaluate indirect effects of possible persistent elongation on kinematics. METHODS: The study was performed as a cross-sectional study based on a population of patients from an RCT regarding non-operative treatment of aATR. Thirty-seven patients out of the 56 in the original RCT participated with at a follow up of 4-5 years after aATR. Primary outcome was Achilles tendon elongation. Additional outcomes were Achilles tendon resting angle (ATRA), calf circumference, passive ankle plantar and dorsiflexion and loading pattern. Foot pressure mapping was performed to measure plantar loading distribution pattern; medial and lateral forefoot peak pressure, heel peak pressure, medial versus lateral loading pattern and timing of heel lift during roll over process. The healthy leg was used as a control. RESULTS: The injured Achilles tendon was significantly elongated by 1.7 (SD 1.6) cm compared to the non-injured leg. A slight delay of 2.6% (SD 6.0) was measured in heel lift in the injured side compared to the non-injured leg. We found no significant difference in forefoot peak pressure, medial and lateral peak pressure as well as heel peak pressure, and no correlation was found between Achilles tendon length and pressure measurements. Finally, dorsiflexion was 1.9°(SD1.28) larger, ATRA 8.1°(SD6.7) larger, and calf circumference 1.6 cm (SD1.1) lower on the injured leg. CONCLUSION: The Achilles tendon was 1.7 cm elongated 4.5 years after the initial injury and significant changes in ATRA, calf circumference and passive dorsiflexion was present. Except for a slight delay in heel lift-off, kinematics during walking was symmetrical between injured and healthy leg, even with an elongated tendon on the injured leg. The clinical relevance of the Achilles tendon elongation is uncertain. LEVEL OF EVIDENCE: II. CLINICAL TRIALS IDENTIFIER: NCT02760784.

Mid-Term Functionality and Survival of 116 HemiCAP® Implants for Hallux Rigidus.

Hallux rigidus can be treated with a proximal hemiarthroplasty (HemiCAP®) to preserve the motion in the first metatarsophalangeal joint and reduce pain. This study examines the functionality, and survival rates of HemiCAP® implants, with or without a dorsal flange. One hundred and five patients were treated with a HemiCAP® (N = 116 HemiCAPs®) between 2006 and 2014. Revision rates, arthrosis score, hallux valgus (HV), intermetatarsal (IM), distal metaphyseal articular angle (DMAA), visual analog scale (VAS) (1-10 points), American Orthopaedic Foot and Ankle Score (AOFAS) MTP-IP (AOFAS 0-100 points), SF-12, range of motion (ROM), and radiographs were analyzed pre- and postoperatively. Statistics: Kaplan-Meier survival analysis, Cox-regression, and paired t tests. At 2, 4, and 6 years, the implant survival was 87%, 83%, and 81%, respectively. All revised due to pain. Dorsal flange, gender, arthrosis, HV, IM, and DMAA did not influence the results. At the mean 5-year follow-up (n = 47) median (range) dorsal ROM was 45° (10°-75°), AOFAS was mean 87.2 ± 10.8, VAS was 2 ± 1.6, and SEFAS was 42 ± 6 points. The dorsal flange made no significant difference for ROM or patient-reported outcome measures compared to the HemiCAP® with no dorsal flange. Twenty-three patients with preoperative data were re-examined, and preoperative dorsal ROM mean difference (confidence interval [CI]) increased 20.7° (13.9°-27.4°), VAS decreased with a mean difference (CI) of -4.7 (-5.8 to 3.5), and AOFAS increased with a mean difference (CI) 26.2 (20.2-32.2) (for all p < .001). The 6-year survival rate of the HemiCAP® implant was 81%. The design change to dorsal flange was not evident clinically. Unrevised patients had significantly less pain, greater ROM, and better foot and ankle function than preoperatively.

Plantar forces mid-term after hemiarthroplasty with HemiCAP for hallux rigidus.

BACKGROUND: The aim of this study was to examine the biomechanical gait effects and range of motion following a proximal hemiarthroplasty with a HemiCap®. METHODS: Forty-one HemiCAP-operated participants with a mean follow-up time of 5 years had plantar force variables (PFVs) examined and compared with their non-operated foot and a control group. PFVs were compared to the MTPJ1 range of motion (ROM), and pain measured by Visual Analog Scale (VAS). RESULTS: The HemiCAP participants' operated feet had higher PFVs laterally on the foot and lower PFVs under the hallux. Dorsal ROM of the operated feet was a median 45° (range 10-75) by goniometer and 41.5 (range 16-80) by X-ray. An increase in ROM decreased the forces under the hallux. Most participants were pain-free. No correlation between pain and PFVs was found. CONCLUSIONS: Increased dorsiflexion decreased the maximum force under the hallux. A mid-term HemiCAP maintains some motion. The decreased PFVs under the hallux may reflect a patient reluctance to load the first ray, although no correlation between plantar forces and pain was found.

Early weight-bearing in nonoperative treatment of acute Achilles tendon rupture did not influence mid-term outcome: a blinded, randomised controlled trial.

PURPOSE: Acute Achilles tendon rupture leads to impaired outcome at short term, but little is known concerning medium-term results. The aim of the present study was to investigate the influence of early weight-bearing on clinical outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. METHOD: The study was performed as a medium-term follow-up on patients included in a randomised controlled trial. Both groups were treated with nonoperative management and controlled early motion. The intervention group was allowed full weight-bearing from day 1, and the control group was non-weight-bearing for 6 weeks. 60 patients were randomised 1:1. Of those, 56 were eligible for inclusion in the medium-term follow-up and 37 participated (18 control, 19 intervention). The outcomes were Achilles tendon Total Rupture Score (ATRS) and heel raise work performed at an average of 4.5 years after the initial injury. Statistical analysis was performed using paired t tests and linear regression. RESULTS: No differences were found between control and intervention groups at 4.5 years. ATRS scores consistently improved in both the intervention and the control groups from 0.5 to 1 year and from 1 to 4.5 years, ending up at 80.5 on average after 4.5 years. Heel raise height kept improving from 0.5 to 4.5 years, reaching a limb symmetry index of 82.4%. The heel raise work improvement from 0.5 to 1 year did not continue. No significant change was found from 1 to 4.5 years, ending at a limb symmetry index of 60%. CONCLUSION: Early weight-bearing did not influence outcome 4.5 years after nonoperative treatment of acute Achilles tendon rupture. The calf muscle of the injured limb performs 40% less work, when compared to the healthy limb, though lifting height recovers better. LEVEL OF EVIDENCE: II. CLINICAL TRIALS IDENTIFIER: NCT02760784.

Inferior reliability of VAS scoring compared with International Society of the Knee reporting system for abstract assessment.

INTRODUCTION: Knowledge of how abstracts may be se-lected for medical conferences in an efficient and reliable manner is sparse. To improve abstract selection, the Danish Orthopaedic Society implemented the International Society of the Knee (ISK) quality-of-reporting system and visual analogue scale (VAS) scoring for abstract evaluation at its 2014 Annual Congress. We sought to find out if a simple VAS score was more reliable than a multiple-question system for assessment of over-all abstract quality. METHODS: A total of 214 abstracts were submitted for review. All abstracts were reviewed by 3 reviewers using a VAS score and the ISK score. Of the 214, 71 abstracts were reviewed again 6 months later to estimate intra-rater agreement. RESULTS: The VAS and the ISK score were poorly correlated (r = 0.64), and the ISK score demonstrated a better intra- and interrater agreement (p < 0.001). The VAS scores of all abstracts were more widely distributed than the ISK scores, which clustered around values in the 50-70 range. Chronbach's alpha for the ISK score was 0.66 (95% confidence interval: 0.62-0.68). CONCLUSIONS: The VAS score has a poorer intra- and interrater agreement than the ISK score, and the two scores do not correlate well. VAS scores were more widely distributed, which is beneficial when selecting a scientific programme, but the score is unreliable. We continue to use the ISK score, although its reliability may still be improved. FUNDING: none. TRIAL REGISTRATION: not relevant.

Quantifying Gait Quality in Patients with Large-Head and Conventional Total Hip Arthroplasty--A Prospective Cohort Study.

We used the Gait Deviation Index (GDI) as method to compare preoperative to postoperative gait changes after uncemented 50 mm (median) large-head and 28/32 mm total hip arthroplasty (THA). We also identified predictors of improvements in GDI. Gait analysis and patient-reported (WOMAC) data were recorded in 35 patients before, 2 and 6-months after treatment. Twenty age-matched adults provided normative gait data. Contrary to our hypothesis, patients who received large-head THA had less improvement in GDI compared with patients who received 28/32 mm THA. The preoperative GDI score was identified as a predictor of postoperative GDI improvement, while WOMAC, age, gender and walking speed were not. This study provides useful information for clinicians and rehabilitation specialists about gait improvement that can be expected after THA.

Metal ion levels and lymphocyte counts: ASR hip resurfacing prosthesis vs. standard THA: 2-year results from a randomized study.

BACKGROUND AND PURPOSE: Wear particles from metal-on-metal arthroplasties are under suspicion for adverse effects both locally and systemically, and the DePuy ASR Hip Resurfacing System (RHA) has above-average failure rates. We compared lymphocyte counts in RHA and total hip arthroplasty (THA) and investigated whether cobalt and chromium ions affected the lymphocyte counts. METHOD: In a randomized controlled trial, we followed 19 RHA patients and 19 THA patients. Lymphocyte subsets and chromium and cobalt ion concentrations were measured at baseline, at 8 weeks, at 6 months, and at 1 and 2 years. RESULTS: The T-lymphocyte counts for both implant types declined over the 2-year period. This decline was statistically significant for CD3(+)CD8(+) in the THA group, with a regression coefficient of -0.04 × 10(9)cells/year (95% CI: -0.08 to -0.01). Regression analysis indicated a depressive effect of cobalt ions in particular on T-cells with 2-year whole-blood cobalt regression coefficients for CD3+ of -0.10 (95% CI: -0.16 to -0.04) × 10(9) cells/parts per billion (ppb), for CD3+CD4+ of -0.06 (-0.09 to -0.03) × 10(9) cells/ppb, and for CD3(+)CD8(+) of -0.02 (-0.03 to -0.00) × 10(9) cells/ppb. INTERPRETATION: Circulating T-lymphocyte levels may decline after surgery, regardless of implant type. Metal ions-particularly cobalt-may have a general depressive effect on T- and B-lymphocyte levels. Registered with ClinicalTrials.gov under # NCT01113762.

Serum chromium levels sampled with steel needle versus plastic IV cannula. Does method matter?

PURPOSE: Modern metal-on-metal (MoM) joint articulations releases metal ions to the body. Research tries to establish how much this elevates metal ion levels and whether it causes adverse effects. The steel needle that samples the blood may introduce additional chromium to the sample thereby causing bias. This study aimed to test that theory. METHODS: We compared serum chromium values for two sampling methods, steel needle and IV plastic cannula, as well as sampling sequence in 16 healthy volunteers. RESULTS: We found statistically significant chromium contamination from the steel needle with mean differences between the two methods of 0.073 ng/mL, for the first sample, and 0.033 ng/mL for the second. No difference was found between the first and second plastic sample. The first steel needle sample contained an average of 0.047 ng/mL more than the second. This difference was only borderline significant. CONCLUSION: The chromium contamination from the steel needle is low, and sampling method matters little in MoM populations. If using steel needles we suggest discarding the first sample.