Radiofrequency ablation prior to total knee arthroplasty does not improve post-surgical pain or recovery: a double-blinded, multi-center, randomized clinical trial.

Background: Radiofrequency ablation (RFA) targeting the genicular nerves is an effective treatment for knee pain due to osteoarthritis. The aim of this study was to determine the effects of two RFA interventions delivered preoperatively on early postoperative pain management and subjective outcomes after total knee arthroplasty (TKA). Methods: One hundred forty-three participants were enrolled in this double blinded, sham-controlled prospective randomized trial. Participants assigned at random to traditional RFA (t-RFA) (n=50), cooled RFA (c-RFA) (n=49), or sham (n=44) procedures prior to TKA. Outcomes were recorded at postoperative day 3, week 1, week 2, week 12, month 6, and month 12 following TKA. Primary outcomes included hospital length of stay (LOS), opioid consumption (reported as MEQ, or daily morphine equivalents), time to narcotic cessation (reported in days), and pain scores (reported as NRS, or Numeric Rating Scale). Secondary outcomes included Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) measures. All side effects and complications were reported. Participants were followed for a year to detect any unexpected side effects. Results: Compared with sham controls, t-RFA and c-RFA did not affect inpatient LOS, pain scores, or opioid consumption. There were no reductions in time to opioid cessation, pain scores, or WOMAC scores at any time point post-TKA. Conclusions: RFA of the genicular nerves prior to TKA did not affect opioid use or time to cessation, pain, or WOMAC scores, following TKA. Current techniques of t-RFA and c-RFA of these specific geniculate nerves preoperatively are not indicated as routine interventions to improve short-term surgical recovery after TKA. Trial Registration: The trial was registered on ClinicalTrials.gov (NCT02925442).

Cadaveric Study of Bone Tissue Temperature During Pin Site Drilling Using Fluoroptic Thermography.

BACKGROUND: Using fluoroptic thermography, temperature was measured during pin site drilling of intact cortical human cadaver bone with a combination of 1-step drilling, graduated drilling, and 1-step drilling with irrigation of 5.0-mm Schanz pins. MATERIALS AND METHODS: A 1440 revolutions per minute constant force drilling was used on tibial diaphyses while a sensor probe placed 0.5 mm adjacent to the drill hole measured temperature. Four drilling techniques on each of the tibial segments were performed: 3.5-mm drill bit, 5.0-mm Schanz pin, 5.0-mm Schanz pin in a 3.5-mm predrilled entry site, and 5.0-mm Schanz pin using irrigation. RESULTS: One-step drilling using a 5.0-mm Schanz pin without irrigation produced a temperature that exceeded the threshold temperature for heat-induced injury in 5 of the 8 trials. With the other 3 drilling techniques, only 1 in 24 trials produced a temperature that would result in thermal injury. This difference was found to be statistically significant (P = 0.003). The use of irrigation significantly reduced the maximum bone tissue temperature in 1-step drilling of a 5.0-mm Schanz pin (P = 0.02). One-step drilling with a 3.5-mm drill bit achieved maximum temperature significantly faster than graduated drilling and drilling with irrigation using a 5.0-mm Schanz pin (P < 0.01). CONCLUSIONS: One-step drilling with a 5.0-mm Schanz pin into cortical bone can produce temperatures that can lead to heat-induced injury. Irrigation alone can reduce the temperatures sufficiently to avoid damage. Predrilling can increase temperatures significantly, but the extent of any injury should be small.

A systematic review of occipital cervical fusion: techniques and outcomes.

OBJECT Numerous techniques have been historically used for occipitocervical fusion with varied results. The purpose of this study was to examine outcomes of various surgical techniques used in patients with various disease states to elucidate the most efficacious method of stabilization of the occipitocervical junction. METHODS A literature search of peer-reviewed articles was performed using PubMed and CINAHL/Ovid. The key words "occipitocervical fusion," "occipitocervical fixation," "cervical instrumentation," and "occipitocervical instrumentation" were used to search for relevant articles. Thirty-four studies were identified that met the search criteria. Within these studies, 799 adult patients who underwent posterior occipitocervical fusion were analyzed for radiographic and clinical outcomes including fusion rate, time to fusion, neurological outcomes, and the rate of adverse events. RESULTS No articles stronger than Class IV were identified in the literature. Among the patients identified within the cited articles, the use of posterior screw/rod instrumentation constructs were associated with a lower rate of postoperative adverse events (33.33%) (p < 0.0001), lower rates of instrumentation failure (7.89%) (p < 0.0001), and improved neurological outcomes (81.58%) (p < 0.0001) when compared with posterior wiring/rod, screw/plate, and onlay in situ bone grafting techniques. The surgical technique associated with the highest fusion rate was posterior wiring and rods (95.9%) (p = 0.0484), which also demonstrated the shortest fusion time (p < 0.0064). Screw/rod techniques also had a high fusion rate, fusing in 93.02% of cases. When comparing outcomes of surgical techniques depending on the disease status, inflammatory diseases had the lowest rate of instrumentation failure (0%) and the highest rate of neurological improvement (90.91%) following the use of screw/rod techniques. Occipitocervical fusion performed for the treatment of tumors by using screw/rod techniques had the lowest fusion rate (57.14%) (p = 0.0089). Traumatic causes of occipitocervical instability had the highest percentage of pain improvement with the use of screw/plates (100% improvement) (p < 0.0001). CONCLUSIONS Based on the existing literature, techniques that use screw/rod constructs in occipitocervical fusion are associated with very favorable outcomes in all categories assessed for all disease processes. For patients requiring occipitocervical arthrodesis for the treatment of inflammatory diseases, screw/rod constructs are associated with the most favorable outcomes, while posterior wiring and onlay in situ bone grafting is associated with the least favorable outcomes. Occipitocervical arthrodesis performed for the diagnosis of tumor is associated with the lowest rate of successful arthrodesis using screw/rod techniques, while posterior wiring and rods have the highest rate of arthrodesis. The nonspecified disease group had the lowest rate of surgical adverse events and the highest rate of neurological improvement.

Complications in the management of Charcot spinal arthropathy.

Charcot spinal arthropathy is a relatively rare, destructive process characterized by a cycle of progressive deformity, destruction, and worsening instability as a result of repetitive trauma and inflammation. It may result from nontraumatic as well as traumatic causes. Historically, patients with severe symptomatic instability have been successfully treated with combined anterior and posterior fusion techniques. The long-term outcomes and potential complications, however, have not been well reported. The authors report on 2 such cases of Charcot spinal arthropathy treated surgically, one with a traumatic and one with a nontraumatic etiology. They include the unique pitfalls encountered while treating these patients, as well as their surgical treatments, complications, and long-term results.

Recurrent atlantoaxial instability due to fracture of the posterior C1 ring: a late finding following posterior C1-C2 fusion using the Halifax clamp.

Although its use has fallen out of favor, the Halifax interlaminar clamp was used for many years to treat cervical instability through a posterior approach. Numerous complications, the majority of which are related to hardware failure, have been reported with the use of the interlaminar clamps and have led to the development of alternative techniques for posterior fusion, such as transarticular screw fixation. This report presents a case of recurrent atlantoaxial instability due to fracture of the posterior C1 ring that occurred 12 years after a posterior C1-C2 fusion with Halifax clamps. To the authors' knowledge, this is the first case report of symmetric fractures through the posterior C1 ring lateral to the site of the Halifax clamps, resulting in recurrent atlantoaxial instability. This report focuses on the surgical management of this complication and provides a review of the literature that pertains to complications following the use of the Halifax clamp to treat atlantoaxial instability.

All-terrain vehicles and associated spinal injuries.

STUDY DESIGN: Case cohort. OBJECTIVE: To illuminate factors associated with all-terrain vehicle (ATV) injuries and injury morphology. SUMMARY OF BACKGROUND DATA: Traditionally thought of as safe, injuries associated with ATVs can be severe and life threatening. In 2005 alone, the US Consumer Product Safety Commission estimated 136,100 injuries and 767 deaths associated with ATVs use and misuse. METHODS: A database of all spine related consults from one institution was reviewed and all patients with spine or spinal cord injuries associated with ATV use were identified. All pertinent demographic, clinical, and radiographic information were collected and analyzed. RESULTS: Thirty-six patients were identified from the spinal cord injury database. The male:female ratio was 11:1 of the ATV injured patient. This is statistically different from the general database population, with a males representing 70% of patients (P < 0.002). The average ATV injured patient was 13.7 years younger than the average database patient (P < 0.001). The incidence of an axial compression or burst type fracture morphology was significantly higher in the ATV injured patient population (50%) compared with the database population as a whole (12%). Factors predisposing patients to injury on ATVs include excessive speed, use of alcohol or controlled substances, use of machinery after dark, and inexperience. CONCLUSION: All-terrain vehicles (ATVs) are currently experiencing enormous popularity in the United States. These recreational vehicles are associated with a higher incidence of axial compression and burst-type fracture morphologies. In general, all-terrain vehicles although highly dangerous leading to death or serious injury can be fun, enjoyable, and safe if proper regulations and safety precautions are implemented and followed.