Ankle Distraction Arthroplasty: A Survivorship Review and Meta-Analysis.

Multiple treatments exist for ankle osteoarthritis. Ankle arthrodesis is the gold standard in late-stage osteoarthritis, but sacrifices range of motion and risks nonunion. Total ankle arthroplasty is typically reserved for low-demand patients as the long-term outcomes are poor. Ankle distraction arthroplasty is a joint sparing procedure which utilizes external fixator frame to unload the joint. This promotes chondral repair and improves function. This study aimed to organize clinical data and survivorship in published papers and direct further research efforts. Thirty-one publications were evaluated and 16 were included in the meta-analysis. The Modified Coleman Methodology Score was used to assess quality of the individual publications. Random effects models were used to estimate the failure risk after ankle distraction arthroplasty. Ankle Osteoarthritis Score (AOS), American Orthopedic Foot and Ankle Score (AOFAS), Van Valburg, and Visual Analog Scores (VAS) all improved postoperatively. Random effects model analysis revealed an overall failure ratio of 11% (95% CI: 7%-15%; p value ≤ .001; I2 = 87.01%) after 46.68 ± 7.17 months follow up, 9% (95% CI: 5%-12%; p value≤0.001 I2=81.59%) with less than 5 years follow-up and 28% (95% CI: 16%-41%; p value≤0.001 I2=69.03%) for patients with more than 5 years follow-up. Ankle Distraction Arthroplasty has promising short to intermediate term outcomes which makes this a reasonable treatment option to delay joint sacrificing surgery. The selection of the optimal candidates and consistent technique would improve research and subsequently outcomes. Based on our meta-analysis, negative prognostic factors include female sex, obesity, ROM < 20°, leg muscle weakness, high activity level, low preoperative pain levels, higher preoperative clinical scores, inflammatory arthritis, septic arthritis, and deformity.

Longitudinal Ultrasound Curriculum Incorporation at West Virginia University School of Medicine: A Description and Graduating Students' Perceptions.

OBJECTIVES: Sonography is a clinical tool being incorporated in multiple medical specialties with evidence of improved patient care and cost. Some schools have begun implementing ultrasound curricula. We hope to build upon that foundation and provide another potential framework of incorporation. There are several barriers, including curricular space, equipment and physical space, adequate faculty, and performing assessment. METHODS: At West Virginia University, we began a longitudinal ultrasound curriculum in 2012 with incorporation of didactic and practical sessions into gross anatomy, our systems-based second-year curriculum, physical diagnosis course, and clinical rotations. We included both written and practical assessment from the onset. After the initial 4 years, the first graduates were surveyed on their perceptions of the curriculum. Responses were correlated with specialty choice and clinical campus site. RESULTS: Based on our survey (90% response rate), students felt sonography was useful for anatomical understanding and patient care. Overall, 93% of our respondents reviewed the curriculum favorably. Qualitative feedback was very positive, with students desiring more ultrasound education and more required components, specifically in clinical rotations. CONCLUSIONS: Based on these results, some changes have already been implemented, including decreased student-to-instructor ratios, more open scan time, and more required components. The breadth of formal assessment has increased. Multiple pilot programs for clinical rotations are being developed. There is an ongoing need for faculty development and continued assessment of ultrasound competency.

Loaded Vertical Jumping: Force-Velocity Relationship, Work, and Power.

The aims of the current study were to explore the pattern of the force-velocity (F-V) relationship of leg muscles, evaluate the reliability and concurrent validity of the obtained parameters, and explore the load associated changes in the muscle work and power output. Subjects performed maximum vertical countermovement jumps with a vest ranging 0-40% of their body mass. The ground reaction force and leg joint kinematics and kinetics were recorded. The data revealed a strong and approximately linear F-V relationship (individual correlation coefficients ranged from 0.78-0.93). The relationship slopes, F- and V-intercepts, and the calculated power were moderately to highly reliable (0.67 < ICC < 0.91), while the concurrent validity F- and V-intercepts, and power with respect to the directly measured values, was (on average) moderate. Despite that a load increase was associated with a decrease in both the countermovement depth and absolute power, the absolute work done increased, as well as the relative contribution of the knee work. The obtained findings generally suggest that the loaded vertical jumps could not only be developed into a routine method for testing the capacities of leg muscles, but also reveal the mechanisms of adaptation of multijoint movements to different loading conditions.

Discharge Readiness after Tricompartment Knee Arthroplasty: Adductor Canal versus Femoral Continuous Nerve Blocks-A Dual-center, Randomized Trial.

BACKGROUND: The authors conducted a randomized, controlled, parallel-arm, superiority study to test the hypothesis that a continuous adductor canal block decreases the time to attain four discharge criteria compared with a continuous femoral nerve block after tricompartment knee arthroplasty. METHODS: Subjects undergoing tricompartment knee arthroplasty were randomized using computer-generated lists to either an adductor canal or femoral perineural catheter (3-day ropivacaine 0.2% infusion) in an unmasked manner. The primary outcome was the time to attain four criteria: (1) adequate analgesia; (2) intravenous opioids independence; (3) ability to stand, walk 3 m, return, and sit down; and (4) ambulate 30 m. RESULTS: Subjects with an adductor canal catheter (n = 39) reached all four criteria in a median of 55 h (interquartile, 42 to 63 h) compared with 61 h (49 to 69 h) for those with a femoral catheter (n = 41; 95% CI, -13 to 1 h; P = 0.12). The percentage of subjects who reached the two mobilization criteria on postoperative days 1 and 2 were 72 and 95% for those with an adductor canal catheter (n = 39), but only 27 and 76% in subjects with a femoral catheter (n = 41; both P < 0.001). Differences in pain scores at rest and intravenous opioid requirements were minimal, but femoral infusion improved dynamic analgesia (P = 0.01 to 0.02). CONCLUSION: Compared with a continuous femoral nerve block, a continuous adductor canal block did not appreciably decrease the time to overall discharge readiness even though it did decrease the time until adequate mobilization, primarily because both groups experienced similar analgesia and intravenous opioid requirements that--in most cases--exceeded the time to mobilization.

Continuous peripheral nerve blocks in the ambulatory setting: an update of the published evidence.

PURPOSE OF REVIEW: To review the evidence recently published involving the use of continuous peripheral nerve blocks (cPNBs) in the ambulatory setting. RECENT FINDINGS: New evidence exists involving the risks and benefits of cPNB in ambulatory patient populations such as pediatric ambulatory and postmastectomy patients. In addition, new related equipment is now available to facilitate ambulatory cPNB. SUMMARY: Recent advancements in equipment for cPNB facilitate the usage in the ambulatory setting. Research-supported ambulatory cPNB indications have expanded to include pediatric subpopulations and major breast surgery, while further evidence mounts for its efficacy in patient populations with previously demonstrated benefits, such as foot, ankle and shoulder surgery.

Thoracic Interfascial Plane Blocks and Outcomes After Minithoracotomy for Valve Surgery.

Introduction. Thoracic interfascial plane blocks are increasingly used for pain management after minimally invasive thoracotomy for valve repair and replacement procedures. We hypothesized that the addition of these blocks to the intercostal nerve block injected by the surgeon would further reduce pain scores and opioid utilization. Methods. In this retrospective cohort study, 400 consecutive patients who underwent minimally invasive thoracotomy for mitral or aortic valve replacement and were extubated within 2 hours of surgery were enrolled. The maximum pain score and opioid utilization on the day of surgery and other outcome variables were compared between patients who received interfascial plane blocks and those who did not. Results.193 (48%) received at least one interfascial plane block while 207 (52%) received no interfascial plane block. Patients who received a thoracic interfascial plane block had a maximum VAS score on the day of surgery (mean 7.4 ± 2.5) after the block was administered which was significantly lower than patients in the control group who did not receive the block (mean 7.9 ± 2.2) (P = .02). Opioid consumption in the interfascial plane block group on the day of surgery was not significantly different from the control group. Conclusion. Compared to intercostal blocks alone, the addition of thoracic interfascial plane blocks was associated with a modest reduction in maximum VAS score on the day of surgery. However, no difference in opioid consumption was noted. Patients who received interfascial plane blocks also had decreased blood transfusion requirements and a shorter hospital length of stay.

Flip Autograft Technique for Anterolateral Femoral Deficiency in Total Knee Arthroplasty.

Anterolateral bone loss of the femur within the trochlear groove presents a unique and rare issue in primary total knee arthroplasty (TKA). Unlike distal and posterior femur bone loss for which most contemporary TKA systems have modular augments, the same does not exist for anterolateral bone loss. We present a technique in which a patient's host bone from the standard distal femoral cuts was used to augment and provide a stable base for cementing of final femoral implants. Currently, the patient has 3-year follow-up with excellent results in terms of pain control with no evidence of component failure on the most recent radiographs. This technique provides a simple solution to a complex problem within primary TKA.

Development of entrustable professional activities for regional anesthesia and pain medicine fellowship training.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) offers descriptions of competencies and milestones but does not provide standardized assessments to track trainee competency. Entrustable professional activities (EPAs) and special assessments (SAs) are emerging methods to assess the level of competency obtained by regional anesthesiology and acute pain medicine (RAAPM) fellows. METHODS: A panel of RAAPM physicians with experience in education and competency assessment and one medical student were recruited to participate in a modified Delphi method with iterative rounds to reach consensus on: a list of EPAs, SAs, and procedural skills; detailed definitions for each EPA and SA; a mapping of the EPAs and SAs to the ACGME milestones; and a target level of entrustment for graduating US RAAPM fellows for each EPA and procedural skill. A gap analysis was performed and a heat map was created to cross-check the EPAs and SAs to the ACGME milestones. RESULTS: Participants in EPA and SA development included 19 physicians and 1 medical student from 18 different programs. The Delphi rounds yielded a final list of 23 EPAs, a defined entrustment scale, mapping of the EPAs to ACGME milestones, and graduation targets. A list of 73 procedural skills and 7 SAs were similarly developed. DISCUSSION: A list of 23 RAAPM EPAs, 73 procedural skills, and 7 SAs were created using a rigorous methodology to reach consensus. This framework can be utilized to help assess RAAPM fellows in the USA for competency and allow for meaningful performance feedback.

Recommendations for effective documentation in regional anesthesia: an expert panel Delphi consensus project.

BACKGROUND AND OBJECTIVES: Documentation is important for quality improvement, education, and research. There is currently a lack of recommendations regarding key aspects of documentation in regional anesthesia. The aim of this study was to establish recommendations for documentation in regional anesthesia. METHODS: Following the formation of the executive committee and a directed literature review, a long list of potential documentation components was created. A modified Delphi process was then employed to achieve consensus amongst a group of international experts in regional anesthesia. This consisted of 2 rounds of anonymous electronic voting and a final virtual round table discussion with live polling on items not yet excluded or accepted from previous rounds. Progression or exclusion of potential components through the rounds was based on the achievement of strong consensus. Strong consensus was defined as ≥75% agreement and weak consensus as 50%-74% agreement. RESULTS: Seventy-seven collaborators participated in both rounds 1 and 2, while 50 collaborators took part in round 3. In total, experts voted on 83 items and achieved a strong consensus on 51 items, weak consensus on 3 and rejected 29. CONCLUSION: By means of a modified Delphi process, we have established expert consensus on documentation in regional anesthesia.

Superficial vs. deep serratus anterior plane block for analgesia in patients undergoing mastectomy: A randomized prospective trial.

STUDY OBJECTIVE: In the initial description of the serratus anterior plane block (SAPB), both superficial and deep SAPB provided effective blockade. The purpose of this study was to investigate the difference in opioid consumption and postoperative analgesia between superficial and deep SAPB for patients undergoing mastectomy. DESIGN: Randomized prospective trial. SETTING: Academic hospital. PATIENTS: 64 women, >18 years of age, ASA I-III, undergoing single or bilateral mastectomy, with and without lymph node biopsy, with and without tissue expander reconstruction. INTERVENTION: Either superficial or deep SAPB by an ultrasound-guided technique in addition to multimodal analgesia. MEASUREMENTS: The primary outcome was opioid consumption in the first 24 h. Secondary outcomes were pain scores, satisfaction scores, incidence of PONV, length of stay and block performance time. RESULTS: Subjects who received a deep SAPB required 30% less oral morphine equivalents (OME) (113.5 mg vs. 147 mg, p = 0.009) and reported lower pain scores. There were no significant differences in satisfaction scores, incidence of PONV, LOS, or block performance time between the two groups. CONCLUSION: There was a significant difference in opioid consumption between the deep and superficial SAPB groups. Subjects in the deep SAPB group had lower pain scores at 12 h; however, the difference was not statistically significant at other time points. While both the superficial and the deep SAPB can be used for post-operative analgesia in patients undergoing mastectomy, our study suggests that the deep SAPB may improve analgesia to a greater degree than the superficial SAPB as shown through decreased opioid consumption of 30% over a 24-h period post-block. CLINICAL TRIAL NUMBER AND REGISTRY URL: clinicaltrials.gov: NCT03154658.

Analysis and Review of Automated Risk Calculators Used to Predict Postoperative Complications After Orthopedic Surgery.

PURPOSE OF REVIEW: To discuss the automated risk calculators that have been developed and evaluated in orthopedic surgery. RECENT FINDINGS: Identifying predictors of adverse outcomes following orthopedic surgery is vital in the decision-making process for surgeons and patients. Recently, automated risk calculators have been developed to quantify patient-specific preoperative risk associated with certain orthopedic procedures. Automated risk calculators may provide the orthopedic surgeon with a valuable tool for clinical decision-making, informed consent, and the shared decision-making process with the patient. Understanding how an automated risk calculator was developed is arguably as important as the performance of the calculator. Additionally, conveying and interpreting the results of these risk calculators with the patient and its influence on surgical decision-making are paramount. The most abundant research on automated risk calculators has been conducted in the spine, total hip and knee arthroplasty, and trauma literature. Currently, many risk calculators show promise, but much research is still needed to improve them. We recommend they be used only as adjuncts to clinical decision-making. Understanding how a calculator was developed, and accurate communication of results to the patient, is paramount.

Anesthesia residency training in regional anesthesiology and acute pain medicine: a competency-based model curriculum.

The Accreditation Council for Graduate Medical Education has shifted to competency-based medical education. This educational framework requires the description of educational outcomes based on the knowledge, skills and behaviors expected of competent trainees. It also requires an assessment program to provide formative feedback to trainees as they progress to competency in each outcome. Critical to the success of a curriculum is its practical implementation. This article describes the development of model curricula for anesthesiology residency training in regional anesthesia and acute pain medicine (core and advanced) using a competency-based framework. We further describe how the curricula were distributed through a shared web-based platform and mobile application.

Interfascial plane blocks.

Many novel interfascial plane blocks have been developed in the last 10 years in the effort to improve perioperative pain management that are safe, efficacious, efficient, and inexpensive. These blocks have been widely adopted into clinical practice despite relatively few high-quality clinical investigations of the techniques and how they affect perioperative outcomes. This article defines interfascial plane blocks, discusses the potential benefits, reviews the most common techniques and evidence supporting their indication, and guides clinicians in selecting an appropriate interfascial plane block for different types of surgical procedures.

Surgical site infiltration: A neuroanatomical approach.

Local anaesthetic administration into a surgical wound blocks the noxious stimuli that result from surgical insult at the site of origin. Surgical site infiltration (also known as local infiltration analgesia) is easy to perform, safe and inexpensive. In addition, it avoids motor blockade, which is particularly relevant for lower limb surgery. The best approach to surgical site infiltration includes meticulous, systematic and extensive surgical site local anaesthetic infiltration in the various tissue planes under direct visualisation before closure of the surgical wound. Local anaesthetic solutions that could be used include bupivacaine HCl, ropivacaine or liposomal bupivacaine diluted with preservative-free normal (0.9%) saline to a total volume depending on the size of the incision. Bupivacaine and ropivacaine are sometimes combined with additives, which have controversial benefits. Continuous wound infusion with preperitoneal wound catheters is an effective pain modality in abdominal surgery and can be used as an alternative for neuraxial analgesia. It is essential that surgical site infiltration is combined with other non-opioid analgesics such as paracetamol and non-steroidal anti-inflammatory drugs to attain the maximum analgesic efficacy.

Topical adjuvants incompletely remove adherent Staphylococcus aureus from implant materials.

Adjuvant treatments including Betadine, Dakin's solution (sodium hypochlorite), or hydrogen peroxide (H2 O2 ) have been attempted to eradicate prosthetic joint infection caused by biofilm or intracellular bacteria. The purpose of this study was to evaluate the in vitro abilities of chemical adjuvants to decrease Staphylococcus aureus (S. aureus) biofilm presence on orthopaedic implant grade materials, including titanium, stainless steel, and cobalt chrome. S. aureus biofilms were grown for 48 h and evaluated for baseline colony forming units/centimeter squared (CFU/cm2 ) and compared to treatments with Betadine, Dakin's solution, H2 O2 , or 1% chlorine dioxide (ClO2 ). Control discs (n = 18) across all metals had an average of 4.2 × 107 CFU/cm2 . All treatments had statistically significant reductions in CFU/cm2 when compared to respective control discs (p < 0.05). For all metals combined, the most efficacious treatments were Betadine and H2 O2 , with an average 98% and 97% CFU/cm2 reduction, respectively. There were no significant differences between reductions seen with Betadine and H2 O2 , but both groups had statistically greater reductions than Dakin's solution and ClO2 . There was no change in antibiotic resistance patterns after treatment. Analysis of S. aureus biofilms demonstrated a statistically significant reduction in biofilm after a five-minute treatment with the modalities, with an average two log reduction in CFU/cm2 . Statement of clinical significance: While statistically significant reductions in CFU/cm2 were accomplished with chemical adjuvant treatments, the overall concentration of bacteria never fell below 105 CFU/cm2 , leading to questionable clinical significance. Further techniques to eradicate biofilm should be investigated. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1599-1604, 2018.

Continuous Adductor Canal Versus Continuous Femoral Nerve Blocks: Relative Effects on Discharge Readiness Following Unicompartment Knee Arthroplasty.

BACKGROUND: We tested the hypothesis that, following unicompartment knee arthroplasty, a continuous adductor canal block decreases the time to reach 4 discharge criteria compared with a continuous femoral nerve block. METHODS: Subjects were randomized to either an adductor canal or femoral perineural catheter (2-day ropivacaine 0.2% infusion) in an unmasked fashion. The primary outcome was the time to attain 4 discharge criteria: (1) adequate analgesia; (2) intravenous opioid independence; (3) ability to independently stand, walk 3 m, return, and sit down; and (4) ambulate 30 m. RESULTS: Subjects with an adductor canal catheter (n = 15) reached all 4 criteria in a median of 35 hours (interquartile range, 24-43 hours), compared with 40 hours (interquartile range, 27-69 hours) for those with a femoral catheter (n = 15; Wilcoxon rank sum test: P = 0.46; log-rank test: P = 0.16). However, the percentages of subjects (adductor canal: femoral) who reached the 2 mobilization criteria were 27%:0% on postoperative day (POD) 0, 93%:53% on POD 1, and 100%:73% on POD 2. Of adductor canal subjects, 100% were discharge ready by POD 2, compared with only 73% of femoral subjects (P < 0.001). CONCLUSIONS: Compared with a continuous femoral nerve block, a continuous adductor canal block did not appreciably decrease the median number of hours to overall discharge readiness, yet did decrease the number of discrete days until discharge readiness. These results are applicable to only unicompartment knee arthroplasty and must be considered preliminary because of the limited sample size of this pilot study.

A-P positioning of medialization thyroplasty in an excised larynx model.

HYPOTHESIS: Posterior positioning of medialization thyroplasty provides the best acoustic and aerodynamic outcomes. STUDY DESIGN: Ex vivo excised canine larynx. METHODS: Unilateral thyroplasty windows were cut in the thyroid cartilages of 10 excised canine larynges. Each larynx was mounted on an artificial lung and the vocal fold opposite the thyroid window was adducted by medializing its arytenoid cartilage. Then, medialization thyroplasty was simulated with a probe placed anterior, central, and posterior in the thyroid window. The glottal area, airway reduction, medialization force, phonation threshold pressure and flow, aerodynamic power, intensity, efficiency, jitter, shimmer, and signal-to-noise ratio (SNR) were measured at each medialization position. RESULTS: Posterior medialization probe placement minimized the glottal area, provided the best voice as determined by perturbation measures and SNR, reduced the work of phonation, and increased efficiency. Anterior and middle probe placement minimized the work of phonation but provided only modest gains in sound quality and decreased sound intensity. Medializing the vocal fold with posterior probe placement required twice as much force as central and anterior probe placement. CONCLUSIONS: The results suggest that posterior medialization provides the greatest improvement in acoustic parameters and efficiency in patients who can tolerate the airway reduction. Middle and anterior medialization can decrease work of phonation, but in this experiment objective improvement in sound quality was limited. Subtle changes in displacement shim contour, especially in middle and anterior locations, have a substantial impact on voice outcome, affirming the value of intraoperative voice assessment.