Assessment of liposome bupivacaine infiltration versus continuous femoral nerve block for postsurgical analgesia following total knee arthroplasty: a retrospective cohort study.

OBJECTIVE: Perioperative pain management is an important aspect of recovery from total knee arthroplasty (TKA) because severe pain can delay ambulation and hospital discharge. The objective of this retrospective sequential cohort study was to determine the impact of local infiltration analgesia using liposome bupivacaine (Exparel 1 ) when compared with a continuous femoral nerve block (FNB) following TKA. METHODS: This retrospective cohort study included consecutive patients who underwent TKA between April 2011 and April 2014, and received one of three interventions. Study Group A received adductor canal infiltration with bupivacaine HCl and knee infiltration with liposome bupivacaine. Study Group B received adductor canal infiltration with liposome bupivacaine and knee infiltration with liposome bupivacaine. The control group received a continuous FNB with ropivacaine HCl delivered via an elastomeric pump. Numeric pain rating scores (NPRS), distance walked, length of stay (LOS), and dose of narcotic medication were the key efficacy variables of interest. RESULTS: A total of 237 patients were included in this study: 98 in Group A, 34 in Group B, and 105 controls. On postoperative day (POD) 0, mean (standard deviation [SD]) NPRSs were similar between Group A (1.8 [1.7]), Group B (2.7 [1.8]), and the control group (2.3 [2.4]). Significantly (p < 0.05) more patients in Group A (58%) and Group B (44%) walked on POD0 than in the control group (0%); almost all patients walked on POD1. The mean (SD) distance walked was also significantly greater (p < 0.05) on POD1 in Group A (193 [203] feet) and Group B (211 [144] feet) than in the control group (46 [73] feet). Mean (SD) LOS was significantly (p < 0.05) shorter in Group B (2.2 [1.2] days), than in the control group (3.2 [0.7] days) and Group A (3.0 [1.7] days). CONCLUSIONS: Local infiltration analgesia using liposome bupivacaine was associated with improved ambulation and shorter LOS following TKA when compared with continuous FNB in this retrospective cohort study.

Osteoarthritis of the knee: isokinetic quadriceps exercise versus an educational intervention.

OBJECTIVE: To evaluate the effects of isokinetic exercise versus a program of patient education on pain and function in older persons with knee osteoarthritis. DESIGN: A randomized, comparative clinical trial, with interventions lasting 8 weeks and evaluations of 12 weeks. SETTING: An outpatient Veterans Affairs Medical Center clinic and an affiliated university hospital. PATIENTS: One hundred thirteen men and women between 50 and 80 years old with diagnosed osteoarthritis of the knee; 98 completed the entire assigned treatment. INTERVENTION: Patients received either a regimen of isokinetic exercise of the quadriceps muscle three times weekly over 8 weeks or a series of 4 discussions and lectures led by health care professionals. MAIN OUTCOME MEASURES: Variables studied for change were isokinetic and isometric quadriceps strength, pain and function determined by categorical and visual analog scales, and overall status using physician and patient global evaluations by the Arthritis Impact Scale, version 2, Western Ontario McMaster's Arthritis Index, and Medical Outcome Study Short Form 36. RESULTS: Both treatment groups showed significant strength gains (p < .05), which occurred over a wider velocity spectrum for the exercise group. Exercised patients also had improved pain scores for more of the variables measured than those receiving education. Both groups had positive functional outcomes and slightly improved measures of overall status. CONCLUSIONS: Isokinetic exercise is an effective and well-tolerated treatment for knee osteoarthritis, but a much less costly education program also showed some benefits.

Trochanteric union following revision total hip arthroplasty.

Ninety-nine patients (106 hips) with a trochanteric osteotomy during revision total hip arthroplasty were evaluated at a minimum of 5 years after surgery. Trochanteric reattachment was done with monofilament cobalt-chromium wires. The influence of the following variables on trochanteric union was examined: a prior trochanteric osteotomy, an existing trochanteric nonunion, trochanteric advancement to the lateral femur, use of vertical (in addition to horizontal) wires through the trochanter, and use of a trochanteric mesh. Overall, union occurred in 92 of the 106 trochanters (87%). Fifty-three of 61 trochanters (86.9%) healed after an initial osteotomy, whereas 34 of 38 (89.5%) healed after a repeat osteotomy. Five of the 7 trochanters with an existing nonunion healed, and 5 of 5 trochanters reattached to a bulk allograft healed. Twenty-nine of 36 trochanters (80.5%) reattached to cancellous bone healed, compared with 58 of 65 (89.2%) that were reattached to the lateral femoral cortex. Ninety percent (83/92) of the trochanters reattached in conjunction with use of a chrome-cobalt mesh healed, compared with 64.3% (9/14) of those without (P < .05). Of the variables studied, only the use of mesh was statistically significant. Osteotomy through a previously healed trochanter, advancement of the trochanter to cortical bone, existing trochanteric nonunion, trochanteric reattachment to a bulk allograft, and lack of vertical wires for fixation did not adversely affect the likelihood of obtaining trochanteric union.

Coralline hydroxyapatite: a bone graft alternative in foot and ankle surgery.

The use of coralline hydroxyapatite has become a viable bone grafting alternative. Its efficacy has been well established through multiple human and animal studies. Coralline hydroxyapatite enhances osteogenesis by providing a biocompatible lattice for the passage and assembly of vascular, fibroblastic, and osteoblastic tissues. It also provides support for surrounding osseous structures. The uses of this material are expanding into the realm of foot and ankle surgery. Its consideration as an appropriate bone graft substitute as well as multiple case studies demonstrating its surgical applicability are discussed. The implants utilized at Thorek Hospital and Medical Center over the past eight years, with an average follow-up of three and one-half years, have proven to be a valuable resource for augmentation where an osseous defect has occurred.

Gait analysis and bivalved serial casting of an athlete with shortened gastrocnemius muscles: a single case design.

Muscle tightness may predispose an athlete to injury. Stretching may help prevent injury by increasing joint passive range of motion and perhaps by increasing ankle range of motion during gait. The purpose of this study was to determine if bivalved serial casting and a positioning program would increase the total dynamic ankle range of motion without increasing the amount of compensatory foot pronation used during gait of an athlete with shortened gastrocnemius muscles. The subject was a 21-year-old male athlete. A three-dimensional camera-based kinematic system was used to collect functional dynamic ankle range of motion data. The Musgrave Footprint system was used to determine the relative amount of foot pronation (by measuring the pronation-supination index and dynamic foot angles). Data were collected for baseline, postintervention, and withdrawal phases. Data were then graphed and descriptively interpreted using means, standard deviations, trend, and level analyses. Following the treatment, the subjects showed an increase in mean total dynamic ankle range of motion without an increase in dynamic foot pronation. Eight weeks after treatment, the increase in mean total dynamic ankle range of motion was maintained and the pronation measurement did not change.

Long-duration metal-on-metal total hip arthroplasties with low wear of the articulating surfaces.

The 20-year performance of metal-on-metal hip articulations has not been reported. Five McKee-Farrar total hip prostheses and one Sivash prosthesis were obtained at revision surgery after a mean implantation time of 21.3 years. A radiographic, histologic, implant, and wear analysis was performed on these total hip implants with cobalt-chrome metal-on-metal articulations. All cases were associated with femoral component loosening, but the bearing surfaces performed remarkably well. The worst case estimate of combined femoral and acetabular linear wear was 4.2 microns per year, about 25 times less than that typically seen with polyethylene. Metal particles and foreign-body inflammation were seen in all cases, but the volume of reactive tissue was small compared with what is generally seen at revision of hips with a polyethylene acetabular bearing. This may be due to a reduced particle burden or a decreased inflammatory reaction to particulate metal, or both. In addition to articular wear, other sources of metal particles included femoral neck impingement on the acetabular rim, stem burnishing, and corrosion. Prosthetic hip reconstructions can fail for many reasons, including suboptimal femoral stem and/or acetabular cup design and/or fixation. By today's standards, the McKee-Farrar and Sivash stem and acetabular component designs are suboptimal; however, after more than 20 years of use, the metal-on-metal bearing surfaces in these cases demonstrated low wear and do not appear to be the cause of failure. Recent advances in total hip arthroplasty, which include improved implant design, materials, manufacturing, and fixation, combined with a better understanding of the mechanisms of implant loosening and failure, suggest that the cobalt-chrome metal-on-metal bearing be reexamined as an alternative to polyethylene when exceptional durability is required.

A comparison of recruitment methods for an osteoarthritis exercise study.

OBJECTIVE: Patient recruitment often involves a great deal of effort and cost. We sought to determine successful recruitment methods for an osteoarthritis (OA) exercise study, and to subsequently focus on using those approaches. METHODS: Eleven methods were developed to recruit subjects for this large research project. Financial constraints ensured that we focused on low-cost measures. Over a 20-month period, the numbers of both total respondents and eventual participants were recorded. RESULTS: Responses were recorded for 263 individuals, and 108 subjects entered the study. The most successful recruitment method was via physician referrals from affiliated clinics. In general, methods that were free of direct cost seemed no less successful than those requiring expenditures. CONCLUSION: Successful subject recruitment, even for a large study, may not require costly advertising. Direct contact and frequent reminders rendered to our own clinics proved most effective, but other free and low-cost approaches were also of benefit.

Objective diagnosis of equinus during gait prior to and following a tibial nerve block.

A quantitative evaluation technique has been developed to assist the clinician in the diagnosis and treatment of ankle equinus deformity. Specifically, the work focuses on accomplishing two major goals: 1) to develop a reliable set of quantitative criteria to assess the degree of dysfunction of the ankle joint during locomotion in patients with equinus deformity; and 2) to determine the effect of various treatment modalities on the ambulatory performance of patients with equinus deformity. A statistically significant difference in two key gait parameters has been demonstrated between healthy subjects and those with equinus deformity.