Generalized Joint Laxity Is Associated With Increased Failure Rates of Primary Anterior Cruciate Ligament Reconstructions: A Systematic Review.

PURPOSE: To investigate patients with generalized joint laxity (GJL) after primary anterior cruciate ligament reconstruction (ACLR) as to the risk of ACLR failure, graft selection success rates, and overall clinical outcomes. METHODS: A systematic review of the PubMed and EMBASE databases was performed to identify studies published from the inception of the databases through February 4, 2020. The inclusion criteria were original studies written in English involving outcomes of patients with GJL who had undergone primary ACLR. RESULTS: Nine studies met the inclusion criteria, which included 1,869 patients. Most underwent isolated bone-patellar tendon-bone (BPTB; n = 1062) or hamstring autograft (n = 696) ACLR. Overall, higher graft failure rates tended to occur in patients with GJL compared with patients without GJL (range per study: 6%-30% vs 0%-12.3%). Inferior results were also found patients with GJL in patient-reported outcome measures and postoperative knee stability determined by KT, Lachman, and pivot-shift tests. BPTB autografts tended to have lower failure rates than hamstring autografts in patients with GJL (range per study: 6%-21% vs 17.6%-30%). Only 1 study determined outcomes of a combined ACLR and extra-articular augmentation in patients with GJL. CONCLUSIONS: Patients with GJL are at an increased risk of inferior outcomes and graft failure after primary ACLR. BPTB autografts may have more favorable stability outcomes compared with hamstring autografts in patients with GJL. However, the reported stability parameters and KT results, even with a BPTB autograft, remain inferior to non-GJL published results, and the added benefit of an extra-articular procedure to supplement the primary ACLR deserves consideration. LEVEL OF EVIDENCE: Level III, systematic review of Level II and III investigations.

The Efficacy of Subchondroplasty for the Treatment of Knee Pain Associated with Bone Marrow Lesions.

CONTEXT: Symptomatic bone marrow lesions on MRI in patients with knee osteoarthritis are strongly associated with progressive deterioration of the joint and an increased risk of progression requiring joint replacement surgery. This study evaluates the efficacy of knee arthroscopy with adjunctive subchondroplasty (i.e. cartilage stabilization) to improve self-rated visual analog scale (VAS) pain scores, rate of conversion to arthroplasty, and patient satisfaction levels. METHODS: A retrospective chart review and phone survey was performed on 12 patients who had undergone knee arthroscopy with adjunctive subchondroplasty for knee pain associated with chronic subchondral bone marrow lesions on MRI. Follow-up for the 12 patients was 36 months on average (range of 12 to 51 months), self-reported paired preoperative and postoperative VAS scores were analyzed in addition to rate of conversion to arthroplasty and patient satisfaction. RESULTS: The results demonstrated statistically significant reductions in mean preoperative VAS scores versus six-week postoperative VAS scores from 7.58 to 1.83 (p < 0.001) in addition to significant reductions in mean preoperative VAS scores to final postoperative VAS scores from 7.58 to 1.60 (p < 0.001). There was no statistically significant association (p > 0.05) with patients' demographic and clinical data (e.g., age, height, weight, BMI, length of symptoms) and rate of revision to total arthroplasty after receiving the arthroscopic subchondroplasty procedure. Out of the 12 patients, two (16.7%) patients went on to conversion to total knee arthroplasty. CONCLUSIONS: In this series, knee arthroscopy with adjunctive subchondroplasty for the treatment of osteoarthritis with symptomatic bone marrow lesions was associated with clinically significant improvements in VAS pain scores. Furthermore, patients who underwent subchondroplasty had a low rate (16.7%) of conversion to total knee arthroplasty at 36-month follow-up.

Tranexamic Acid in the Treatment of Hip Fractures: A Clinical Review.

INTRODUCTION: Although regularly used as a method to reduce blood loss in elective orthopedic procedures (e.g., total hip and knee arthroplasty), there currently is little evidence concerning the optimal dosage, timing and route for the use of tranexamic acid to reduce postoperative blood loss in hip fracture repair. SUMMARY OF THE EVIDENCE: The current literature suggests that tranexamic acid may be used to reduce postoperative blood loss in addition to reducing the risk of requiring blood transfusions following the surgical repair of hip fractures. Furthermore, it may have the potential to improve patient outcomes and decrease the overall costs of caring for this patient population. CONCLUSIONS: Further studies are needed to truly gauge the effect of tranexamic acid on long-term patient outcomes and hospital costs.

Liposomal bupivacaine reduces opioid consumption and length of stay in patients undergoing primary total hip arthroplasty.

BACKGROUND: Optimising postoperative pain management after total hip arthroplasty (THA) has been associated with improved patient outcomes. However, conclusions regarding the role of liposomal bupivacaine (LB) during THA remain mixed. The purpose of this study was to determine whether substituting a standard intraoperative wound infiltrate with LB as part of a multimodal pain management protocol would decrease subsequent opioid consumption and overall length of hospital stay in patients undergoing primary THA. METHODS: Data was retrospectively collected on 170 consecutive patients who underwent primary THA at a single institution from January 2014 to October 2014. Outcomes from the first 85 patients who received intraoperative LB were compared to the prior 85 patients who received a standard intraoperative "cocktail" without LB. The remainder of the multimodal pain management protocol was identical between groups. RESULTS: Total continuous and categorical postoperative hospital opioid consumption rates in the LB subgroup were significantly lower than the non-LB subgroup ( p < 0.001). The use of LB was associated with a relative reduction in opioid consumption on the day of surgery ( p = 0.001), postoperative day 1 ( p < 0.001), postoperative day 2 ( p < 0.001) and postoperative day 3 ( p < 0.001). Patients who received LB had decreased length of stay ( p = 0.001) and were discharged on lower doses of opioids. CONCLUSION: Substituting to LB from a standard wound infiltrate during primary THA, in addition to our standard multimodal pain management protocol, resulted in significantly lower postoperative opioid consumption and decreased length of stay.

Femoral Osteomyelitis Presenting as a Pathologic Fracture in a 53 Year Old Male: A Rare Case Report.

INTRODUCTION: Hematogenous osteomyelitis of long bones in immunocompetent adults is extremely rare and uncommonly presents as a pathological fracture. CASE REPORT: A 53-year-old Caucasian male presented with an atraumatic mid-shaft femur fracture secondary to hematogenous osteomyelitis. The organism was found to be Streptococcus anginosus. The patient required multiple surgical debridements and was treated with an antibiotic-impregnated cement rod and external fixator along with IV Rocephin. Furthermore, the patient was on chronic Carbamazepine therapy for the refractory bipolar disorder. We discuss the effect cytochrome p450 inducing medications have on bone health and how this may have contributed to this rare presentation of pathologic fracture. CONCLUSION: We report a rare case of femoral osteomyelitis presenting as a pathologic fracture. Treatment involves multiple surgeries and an extended recovery.