Peri-articular local infiltration analgesia versus femoral nerve block for postoperative pain control following anterior cruciate ligament reconstruction: Prospective, comparative, non-inferiority study.

INTRODUCTION: Femoral nerve block (FNB) is considered as a major advance in anterior cruciate ligament (ACL) reconstruction as it reduces the need for parenteral opioids. However, the incidence of transient or even permanent neurological deficits due to the FNB is estimated at 1.94% after knee surgery. The primary objective of this study was to compare local infiltration analgesia (LIA) to FNB during ACL reconstruction procedures. The study hypothesis was that LIA was not less effective than FNB on early postoperative pain. PATIENTS AND METHODS: A retrospective analysis of data collected prospectively in the FAST cohort included a series of continuous patients who underwent primary repair for isolated ACL with a hamstring graft in 2013-2014. Changes in our anesthesia practices over time allowed us to form three successive groups: Group 1 - FNB, Group 2 - FNB+LIA, Group 3 - LIA only. Ultrasound-guided FNB was done pre-operatively. The LIA was done at the end of the procedure by the surgeon with systematic infiltration of all skin incisions and the hamstring donor site; no intra-articular injections were performed. The primary endpoint was the average early postoperative pain (Days 0-3) described by the patient on a visual analogue scale (0-10). Sample size calculation pointed to 36 subjects being needed per group for a non-inferiority study. RESULTS: The study involved 126 patients: G1=42, G2=38, G3=46. The patients were comparable at enrolment. The average early postoperative pain levels were 3.1±2.4, 2.8±2.0 and 2.5±2.2, respectively (P=0.66). A trend toward higher intake of tramadol was noted in the LIA group on D0 to D3, with a significant trend test on Day 1 (P=0.03) and Day 2 (P=0.02). CONCLUSION: After reconstruction of isolated ACL tears with a hamstring graft, FNB is not more effective than LIA on patients' early postoperative pain. Patients who received a FNB consumed significantly less opioid-like analgesics. LEVEL OF EVIDENCE: III - Prospective, comparative, non-randomized study.

Outpatient Latarjet surgery for gleno-humeral instability: Prospective comparative assessment of feasibility and safety.

BACKGROUND: Some surgical procedures are rarely done on an outpatient basis. The primary objective of this study was to assess the safety of outpatient surgical shoulder stabilisation using the Latarjet procedure. HYPOTHESIS: The Latarjet procedure is safe when performed on an outpatient basis provided the patients are managed according to a specifically designed programme starting at the decision to undergo surgery and ending at the end of the early postoperative period. PATIENTS AND METHODS: Consecutive patients with unidirectional anterior shoulder instability managed in 2013-2014 by primary open, minimally invasive surgery involving coracoid process transfer as described by Latarjet was included prospectively. One of the surgeons routinely offered outpatient surgery to patients who met none of the usual exclusion criteria (age>60years, ASA 3-4, and long distance from home to hospital). Standardised protocols were applied for anaesthesia and analgesia. The primary evaluation criterion was failure of the admission modality, defined as inpatient admission of a patient after outpatient surgery either without prior discharge or within 1week after discharge. Secondary evaluation criteria were early postoperative symptoms and functional outcomes after at least 1year. All self-reported criteria were entered online by the patients. RESULTS: Of 46 included patients, 17 had outpatient surgery and 29 inpatient surgery. There were 41 males and 5 females, with a mean age of 25.3±6.4years. No significant baseline differences were found between the two groups. None of the outpatients required inpatient admission or readmission. No postoperative complications were recorded. After a mean follow-up of 18.5±5.2months, the two groups showed no significant differences for return to sports, apprehension, avoidance behaviours, or functional outcomes. Most patients were satisfied with their management and outcomes. CONCLUSION: No serious adverse events were recorded in this first French prospective evaluation of the safety of open, minimally invasive shoulder stabilisation by the Latarjet procedure performed on an outpatient basis. Thus, in selected patients, the risks of outpatient surgery are similar to those of inpatient surgery. LEVEL OF EVIDENCE: III, prospective, comparative, non-randomised study.

Inefficacy of Kinesio-Taping(®) on early postoperative pain after ACL reconstruction: Prospective comparative study.

INTRODUCTION: Kinesio-Taping(®) (K-Tape) is used in sports traumatology with the aim of reducing pain and improving blood and lymph circulation. The main objective of the present study was to assess the efficacy of K-Tape on early postoperative pain after anterior cruciate ligament (ACL) reconstruction. The study hypothesis was that K-Tape significantly decreases pain. METHOD: A prospective non-randomized comparative study was conducted in 2013-2014 and included all patients who underwent primary ACL reconstruction by hamstring graft. Analgesia was standardized. Two groups, "K-Tape" and "controls", were formed according to the days on which the study physiotherapist was present. The K-Tape compression/decompression assembly was applied immediately postoperatively and maintained for 3days. Patients filled out online questionnaires. The main assessment criterion was mean postoperative pain (D0-D3) on a 0-to-10 scale. Secondary criteria were analgesia intake on the three WHO levels, awakening during the night of D0 due to pain, signs of postoperative discomfort, and patient satisfaction. RESULTS: Sixty patients (30 per group) were included, 57 of whom could be assessed: 28 K-Tape, 29 controls; 44 male, 13 female; mean age, 30.9±8.9 years. At inclusion, the two groups were comparable. There was no significant difference in mean (D0-D3) knee pain intensity: 3.8±2.2 for K-Tape, and 3.9±2 for controls (P=0.93). Analysis of variance (ANOVA) found no significant intergroup difference in evolution of pain (P=0.34). There were no other significant differences on the other assessment criteria. CONCLUSION: K-Tape showed no efficacy on early postoperative pain following ACL reconstruction. LEVEL OF EVIDENCE: III; prospective non-randomized comparative study.

Iliac Crest Avulsion Fracture in a Young Sprinter.

Avulsion fracture of the iliac crest is an uncommon pathology. It usually occurs in teenagers during sport activities, more common in boys. We report a case of 16-year-old male competitive sprinter, who had an avulsion of a part of the iliac crest and the anterior-superior iliac spine during a competition. The traumatism occurred during the period of acceleration phase out of the blocks which corresponds to the maximum traction phase on the tendons. Then a total loss of function of the lower limb appears forcing him to stop the run. X-ray and CT scan confirmed the rare diagnosis of avulsion of the quasitotality of the iliac crest apophysis, corresponding to Salter 2 fracture. We performed an open reduction and internal fixation with two screws, allowing a return to sport after 3 months and his personal best record in the 100 meters at the 6th postoperative month.

Diagnostic value of the GNRB ® in relation to pressure load for complete ACL tears: A prospective case-control study of 118 subjects.

INTRODUCTION: The GNRB(®) is a reliable, validated arthrometer. A pressure pad exerts 0 to 250 Newtons of pressure on the upper calf. The goal of this study was to compare the diagnostic value of the different pressure loads that are usually applied for the diagnosis of complete anterior cruciate ligament (ACL) tears. Our hypothesis was that a load of 200N would be sufficient to diagnose these tears. PATIENTS AND METHODS: A prospective comparative case-control study was performed in 2012. One group included all the male athletes aged 15 to 21 who presented with a complete ACL tear confirmed by arthroscopy (the study group). The control group included male soccer players in a training center aged 15 to 19 with no history of knee injuries (the control group). Anterior laxity was measured in both knees by the same experienced operator using the GNRB(®) system. The main judgment criteria were the diagnostic values of each pressure load evaluated by the area under the curve (AUC), from "Null" (AUC < 0.5) to "Perfect" (AUC = 1). RESULTS: This study included 118 men: 64 in the study group, mean age 18.1 ± 2.3-years-old, who were mainly soccer players (39/64) or rugby men (16/64) and 54 control subjects, mean age 17.3 ± 1.5-years-old. Three hyperalgesic patients could not receive a pressure load of 250N. The mean differential laxity was significantly higher in the control group, whatever the pressure load (P < 10(-5)). The test was "highly informative" for all loads (0.9 ≤ AUC < 1). Analysis of the AUC revealed a diagnostic value in descending order of: 200N(0.97[0.94-1]) > 134N(0.97[0.93-0.99]) > 250N(0.96[0.93-0.99]) > 89N(0.95[0.90-0.99]). CONCLUSION: The GNRB(®) at 200N was shown to be sufficient to diagnose complete ACL tears. Applying a pressure load of 250N does not appear to be useful.

Management of recent first-time anterior shoulder dislocations.

The management of a first episode of anterior shoulder dislocation starts with an analysis of the causative mechanism and a physical examination to establish the diagnosis. Based on the findings, the case can be classified as simple or accompanied with complications, most notably vascular or nerve injuries. Two radiographs perpendicular to each other should be obtained to confirm the diagnosis then repeated after the reduction manoeuvres. Additional imaging studies may be needed to assess concomitant bony lesions (impaction lesions or fractures). External reduction should always be attempted after premedication appropriate for the severity of the pain. General anaesthesia may be necessary. There is no consensus regarding the optimal reduction technique, although the need for gentle manoeuvres that do not cause pain is universally recognised. Immobilisation currently involves keeping the elbow by the side with the arm internally rotated for 3-6weeks depending on patient age. Vessel and nerve injuries are rare but can cause major functional impairments. Follow-up evaluations are in order to check the recovery of normal function, which may be more difficult to achieve in patients with concomitant lesions; and to detect recurrent shoulder instability and rotator cuff lesions. At the acute phase, surgery is indicated only in patients with complications or after failure of the reduction manoeuvres. Shoulder immobilisation with the arm externally rotated and surgical treatment of the first episode are controversial strategies that are discussed herein.

Results of surgical treatment of calcaneus insertional tendinopathy in middle- and long-distance runners.

PURPOSE: Calcaneus insertional tendinopathy in runners is common and involves important therapeutic controversies. The object of this study was to determine the delay and level of return to sport after insertional surgery in runners, with and without tendon damage. METHODS: Eighteen runners underwent surgery for insertional calcaneus tendinopathy. Nine required an exostosectomy/bursectomy, and nine others required a tendon reinsertion/autograft. All patients were clinically assessed pre- and post-operatively with AOFAS scores and post-operatively with ATRS. This series included analysis of "pure conflicts" and "severe insertional lesion" scores. If the insertional tendon was free or the lesion was smaller than 50 %, the group was classified as "pure conflict/minor tendon damage". In the situation in which a loss of tendon occurred or the tendon lesion was greater than 50 %, the group was classified as "major tendon damage". Pre-operatively, the AOFAS "overall", "pure conflicts/minor tendon damage" and "major tendon damage" groups' scores were 58.5 ± 15, 68.2 ± 8.8 and 48.9 ± 13.9/100, respectively. RESULTS: Post-operatively, the AOFAS "overall", "pure conflicts/minor tendon" and "major tendon damage" groups' scores were 93.7 ± 8.2, 93.2 ± 10.2 and 95.2 ± 5.7/100, respectively. The AOFAS score gain for each group was, respectively, 35.2 ± 19, 24 ± 17 and 46.3 ± 14.1. The ATRS "overall", "pure conflicts/minor tendon damage" and "major tendon damage" groups' scores were 81.5 ± 14.9, 78.3 ± 20.1 and 84.7 ± 6.7/100, respectively. The global sport recovery delay was 9.3 ± 4.1 months; it was 6 ± 3.3 months for the pure conflict/minor tendon damage subgroup and 10 ± 4.6 months for the severe tendon damages subgroup. CONCLUSION: Achilles insertional tendinopathy surgery on this population results in few complications with good functional results if the surgical technique is adapted to the type of tendon injury. The clinical relevance of this study is that it highlights the various forms of calcaneus insertional tendinopathy and various treatment options. The authors show that in the case of major tendon damage, time to return to sport is longer.