Do Relaxation Exercises Decrease Pain After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial.

BACKGROUND: Pain after rotator cuff repair is commonly managed with opioid medications; however, these medications are associated with serious adverse effects. Relaxation exercises represent a potential nonpharmacologic method of pain management that can be easily implemented without substantial adverse effects; however, the effects of relaxation exercises have not been studied in a practical, reproducible protocol after arthroscopic rotator cuff repair. QUESTIONS/PURPOSES: (1) Does performing relaxation exercises after arthroscopic rotator cuff repair (ARCR) decrease pain compared with standard pain management medication? (2) Does performing relaxation exercises after ARCR decrease opioid consumption? (3) What proportion of patients who used the relaxation techniques believed they decreased their pain level, and what proportion continued using these techniques at 2 weeks? (4) Does performing relaxation exercises after ARCR affect shoulder function? METHODS: During the study period, 563 patients were eligible for inclusion; however, only 146 were enrolled, randomized, and postoperatively followed (relaxation group: 74, control group: 72); 68% (384 of 563) of patients were not contacted due to patient and research staff availability. Thirty-three patients were unenrolled preoperatively or immediately postoperatively due to change in operative procedure (such as, only debridement) or patient request; no postoperative data were collected from these patients. Follow-up proportions were similar between the relaxation and control groups (relaxation: 80%, control: 81%; p = 0.90). The relaxation group received and reviewed educational materials consisting of a 5-minute video and an educational pamphlet explaining relaxation breathing techniques, while the control group did not receive relaxation education materials. Patients recorded their pain levels and opioid consumption during the 5 days after ARCR. Patients also completed the American Shoulder and Elbow Surgeons shoulder score preoperatively and 2, 6, 13, 18, and 26 weeks postoperatively. Linear mixed models were created to analyze postoperative pain, opioid consumption measured in morphine milligram equivalents (MMEs), and shoulder function outcomes. A per-protocol approach was used to correct for patients who were enrolled but subsequently underwent other procedures. RESULTS: There was no difference in pain scores between the relaxation and control groups during the first 5 days postoperatively. There was no difference in pain scores at 2 weeks postoperatively between the relaxation and control groups (3.3 ± 3 versus 3.5 ± 2, mean difference -0.22 [95% CI -1.06 to 0.62]; p = 0.60). There was no difference in opioid consumption during the first 5 days postoperatively between the relaxation and control groups. The use of relaxation exercises resulted in lower 2-week narcotics consumption in the relaxation group than in the control group (309 ± 241 MMEs versus 442 ± 307 MMEs, mean difference -133 [95% CI -225 to -42]; p < 0.01). Sixty-two percent (41 of 66) of patients in the relaxation group believed the relaxation exercises decreased their pain levels. Fifty-two percent (34 of 66) were still performing the exercises at 2 weeks postoperatively. During the 6-month follow-up period, there was no difference in shoulder function between the relaxation and control groups. CONCLUSION: The preoperative administration of quick, basic relaxation exercises allowed patients to use appreciably lower opioid analgesic doses over the first 2 weeks after ARCR, without any worsening of pain scores. We consider this result promising but preliminary; it is possible that a more intense mindfulness intervention-the one we studied here was disseminated using only a 5-minute video-would deliver reductions in pain and further reductions in opioid usage. LEVEL OF EVIDENCE: Level II, therapeutic study.

Anterior Cruciate Ligament Reconstruction in Young Females: A Systematic Review of Patellar Tendon Versus Hamstring Tendon Autografts.

A systematic review was performed to compare patellar tendon-bone (BTB) and hamstring tendon (HS) autografts following anterior cruciate ligament reconstruction in young females, young patients, or females. One study compared BTB and HS in young females and found a lower rate of graft failure with BTB (P<.02). Of the 11 studies that made this comparison in females, 1 reported decreased laxity in females with BTB (P=.035). Of 4 studies comparing autografts in young patients, 1 reported a decreased rate of graft failure with BTB (P=.036). Further studies making this comparison specifically in young females are warranted. [Orthopedics. 2019; 42(3):e295-e304.].

MR imaging of BioCartilage augmented microfracture surgery utilizing 2D MOCART and KOOS scores.

OBJECTIVES: BioCartilage is a novel scaffold-based microfracture augmentation technique that has been shown to aid in chondrogenic differentiation of adult progenitor cells resulting in formation of more hyaline-like cartilage. As this cartilage repair technique becomes more commonplace, it is essential that the musculoskeletal radiologist and orthopedic surgeon gain familiarity with the surgical technique and its post-operative MR imaging findings. METHODS: We present several case studies regarding MRI findings (modified clinical 2D MOCART) and clinical outcome (KOOS) scores in patients who have undergone this novel surgical procedure. For data analysis KOOS scores where dichotomized to scores greater or less than 80, and MOCART scores were dichotomized to scores greater or less than 50. A fisher exact test was then performed to determine if there was any correlation between parameters of the modified 2D MOCART and KOOS scores (Tables 2 and 3). RESULTS: Marrow elements travel through the microfracture holes and interact with the scaffold created by BioCartilage, rather than creating their own fibrin scaffold, as is typically anticipated from a marrow stimulation procedure. Interestingly, the amount defect fill, presence of an intact surface, intact subchondral bone, or lack of effusion did not correlate with positive outcomes. Parameters that trended towards significance included presence of adhesions and subchondral lamina. Completeness of cartilage interface, homogeneity, and signal intensity also failed to reach statistical significance. In our experience, patients that demonstrated mild repair tissue surface irregularity, but with preservation of greater than 50% thickness compared to surrounding native cartilage, mild irregularity of subchondral plate, with vertical low signal intensity lines (sequela of prior microfracture surgery), and mild or no bone marrow edema pattern demonstrated higher KOOS scores. CONCLUSION: Biocartilage in conjunction with microfracture is an encouraging cartilage restoration technique that promotes regeneration of more robust hyaline-like cartilage compared to the fibrocartilage formed after conventional microfracture. The T2 mapping properties of the repair tissue after successful BioCartilage augmented microfracture surgery are very similar to that of the adjacent native cartilage. Although there appear to be characteristic trends in a successful repair, further research is warranted to elucidate any correlations between specific characteristics of the repair and patient clinical outcomes.

The Meniscal Comma Sign: Characterization and Treatment of a Displaced Fragment in the Meniscotibial Recess.

Displaced parrot beak flap tears in the meniscotibial recess are complex tears of the meniscus that begin as central radial tears and progressively extend toward the periphery, creating a detached fragment. These tears have not been described in the literature, but the authors have described them as the "meniscal comma sign" based on their appearance on magnetic resonance imaging. Displaced fragments are clinically significant because of the pain and mechanical symptoms they can cause as a result of tenting of the deep medial collateral ligament. Failure to distinguish these tears from meniscal extrusion and superimposed osteoarthritis on magnetic resonance imaging can cause them to be misinterpreted or missed, leading to a delay in treatment. [Orthopedics. 2018; 41(3):e442-e444.].

A prospective analysis of glove perforation in primary and revision total hip and total knee arthroplasty.

Literature in regard to glove perforation rates in revision total joint arthroplasty (TJA) is scarce. Our purpose was to determine the incidence of perforation in revision TJA. Gloves from all scrubbed personnel were tested based on the American Society for Testing and Materials. A total of 3863 gloves were collected from 58 primary and 36 revision arthroplasty cases. Surgeons had a 3.7% outer-glove perforation rate in primary TJA compared with 8.9% in revision TJA. When both gloves were perforated, the outer-glove perforation was recognized intraoperatively 100% of the time, and the inner-glove perforation was noted only 19% of the time. The surgeon has the highest rate of glove perforation. Outer-glove perforations should prompt careful inspection of the inner glove.

Revision for recurrent instability: what are the predictors of failure?

Dislocation is a common complication following total hip arthroplasty (THA). In this study, we evaluated treatment strategies in patients undergoing revision THA for instability. A total of 156 hips in 154 patients underwent revision THA for instability between 2000 and 2007 at our institution. Demographic data and surgical treatment used were analyzed to determine risk factors for failure. Revision treatments included acetabular components in 100 hips, liner exchange in 56 hips, and femoral and acetabular components in 13 hips. Thirty-three (21.2%) had further dislocation. Isolated liner revision (P = .004), previous revision arthroplasty (P < .05), and the use of a 28-mm femoral head were associated with higher failure rates. A total of 20.3% (12/59) of constrained liners failed. Isolated liner exchange, history of revision, and use of a 28-mm head were associated with failure in revision THA for instability.