Scoping review of early pain-related outcome domains and measurement instruments after degenerative lumbar spine surgery.

BACKGROUND: Optimization of perioperative pain interventions in lumbar spine surgery could reduce the incidence of acute and persistent postoperative pain and opioid consumption. Standardization in early outcome measurement provides a solid foundation for future clinical and research practices and should be integrated in core outcome sets for long-term treatment outcome evaluations. This scoping review provides an overview of outcomes used when evaluating early perioperative pain interventions after lumbar spine surgery. OBJECTIVES: To create an overview of outcome domains and measurement instruments previously used in research on perioperative pain management for degenerative lumbar spine surgery. EVIDENCE REVIEW: A scoping review was performed to identify articles comprising outcome evaluations in adult patients who undergo degenerative lumbar spine surgery, mentioning perioperative pain interventions. 75 articles were included for review. Data on study characteristics, outcome domains and measurement instruments were extracted and structured using the three-tiered hierarchy of Porter. FINDINGS: 12 outcome domains were identified: pain intensity (93.3%), adverse events (76%), analgesic consumption (70.7%), length of stay (52%), patient satisfaction (24%), daily functioning (22.7%), (early) mobilization (22.7%), quality of life (12%), mortality (9.3%), quality of recovery (6.7%), physical function (4%), and quality of sleep (2.7%). 63 corresponding measurement instruments were found. CONCLUSIONS: This review portrays an extensive overview of outcome measurements used in perioperative pain management in lumbar spine surgery. A lack of consensus on the set of indicators exists. This scoping review is a call for action to create consensus on how to evaluate perioperative pain interventions in degenerative lumbar spine surgery.

Complications of a self-centering sliding tibial tubercle osteotomy for patellofemoral complaints; low incidence of non-union and fracture.

BACKGROUND: A tibial tubercle osteotomy (TTO) is a commonly performed procedure in young and active patients with patellofemoral complaints. Previous small patient series demonstrated a relatively high risk of complications, which appear to be technique dependent. The purpose of this large case series is to quantify the risk of procedure specific postoperative complications related to a uniform self-centering TTO technique in a large cohort, performed by two different surgeons in one center. HYPOTHESIS: We hypothesize that non-union or fracture occurs in less than 1% of the procedures. PATIENTS AND METHODS: Five hundred and twenty-nine knees in four hundred and forty-seven patients who underwent a self-centering TTO with at least one year of follow-up were included. We performed a retrospective cohort review. Tibial fracture, osteotomy non-union, neurovascular complications, infection and wound complications that required surgical intervention were defined as major complications, miscellaneous complications were defined minor. RESULTS: The major finding in this study is the low incidence of non-union (0.6%) and tibial fracture (0.4%). In total 9 (1.7%) major complications were reported. Minor complications included superficial wound infection in five patients, two patients had a venous thrombo-embolism (VTE). CONCLUSION: A self-centering TTO is a relatively safe technique with a low number of non-union and fracture. LEVEL OF EVIDENCE: Level IV, retrospective cohort study.

A detaching, V-shaped tibial tubercle osteotomy is a safe procedure with a low complication rate.

INTRODUCTION: In patients with recurrent patellar dislocations, a tibial tubercle osteotomy (TTO) can be indicated to correct patella alta or an increased trochlear groove-tibial tubercle distance. Several surgical techniques are described. Previous studies emphasize that detaching osteotomies results in devascularisation, which can lead to non-union and tibial shaft fractures. The aim of this study was to report the complication rates directly related to the surgical technique of a V-shaped TTO, where the tubercle is completely released from its periosteum using a step-cut osteotomy. METHODS: The retrospective case series comprised a large cohort of 263 knees with patella alta in 203 patients who underwent a V-shaped TTO, with or without additional realignment procedures, between March 2004 and October 2017. Data were obtained from available patient files. Complications were defined as minor or major. RESULTS: Thirteen major complications were registered (4.9%) including two tibial fractures (0.75%) and one non-union (0.37%). Five complications (1.9%) were defined as minor. Removal of the screws because of irritation or pain was seen in 22 cases (8.2%). CONCLUSION: A V-shaped TTO is a safe procedure. The presumed higher risk for tibial fractures or pseudo-arthrosis could not be confirmed.

Complications of medial patellofemoral ligament reconstruction using two transverse patellar tunnels.

PURPOSE: The aim of this study was to report the complication rate after a medial patellofemoral ligament (MPFL) reconstruction using transverse patellar tunnels in a retrospective case series performed in a single institution. METHODS: Case series of 179 patients (192 knees) that had an MPFL reconstruction, with or without additional bony realignment procedures, between January 2009 and March 2015. Data were obtained from available patient charts. RESULTS: Thirty-nine complications (20.3 %) were registered. Twenty-seven of these (14.7 %) were minor. Seven patients (3.6 %) sustained a patellar fracture without adequate trauma. Male gender was a risk factor for patellar fracture (p < 0.001). Sixteen (8.1 %) reported recurrence of instability, of whom 10 (5.1 %) were defined as objective instability (reported dislocation and positive apprehension test). CONCLUSION: This is largest patient series to date in which the complications after a two tunnel MPFL reconstruction are described. The use of transverse patellar tunnels increases the risk of sustaining a patellar fracture. LEVEL OF EVIDENCE: IV.

Patellofemoral Pressure Changes After Static and Dynamic Medial Patellofemoral Ligament Reconstructions.

BACKGROUND: Reconstructing the medial patellofemoral ligament (MPFL) has become a key procedure for stabilizing the patella. Different techniques to reconstruct the MPFL have been described: static techniques in which the graft is fixed rigidly to the bone or dynamic techniques with soft tissue fixation. Static MPFL reconstruction is most commonly used. However, dynamic reconstruction deforms more easily and presumably functions more like the native MPFL. PURPOSE/HYPOTHESIS: The aim of the study was to evaluate the effect of the different MPFL fixation techniques on patellofemoral pressures compared with the native situation. The hypothesis was that dynamic reconstruction would result in patellofemoral pressures closer to those generated in an intact knee. STUDY DESIGN: Controlled laboratory study. METHODS: Seven fresh-frozen knee specimens were tested in an in vitro knee joint loading apparatus. Tekscan pressure-sensitive films fixed to the retropatellar cartilage measured mean patellofemoral and peak pressures, contact area, and location of the center of force (COF) at fixed flexion angles from 0° to 110°. Four different conditions were tested: intact, dynamic, partial dynamic, and static MPFL reconstruction. Data were analyzed using linear mixed models. RESULTS: Static MPFL reconstruction resulted in higher peak and mean pressures from 60° to 110° of flexion (P < .001). There were no differences in pressure between the 2 different dynamic reconstructions and the intact situation (P > .05). The COF in the static reconstruction group moved more medially on the patella from 50° to 110° of flexion compared with the other conditions. The contact area showed no significant differences between the test conditions. CONCLUSION: After static MPFL reconstruction, the patellofemoral pressures in flexion angles from 60° to 110° were 3 to 5 times higher than those in the intact situation. The pressures after dynamic MPFL reconstruction were similar as compared with those in the intact situation, and therefore, dynamic MPFL reconstruction could be a safer option than static reconstruction for stabilizing the patella. CLINICAL RELEVANCE: This study showed that static MPFL reconstruction results in higher patellofemoral pressures and thus enhances the chance of osteoarthritis in the long term, while dynamic reconstruction results in more normal pressures.

Tape versus cast for non-operative treatment of primary patellar dislocation: a randomized controlled trial.

PURPOSE: We hypothesized that taping results in better short-term functional outcome and comparable redislocation rates. METHODS: In a prospective randomised clinical trial, 18 patients with a primary patellar dislocation ≥18 years old without accompanying fractures or previous surgery to the knee were included. After 1 week of dorsal splinting, they were randomized into two groups: taping and cylinder cast immobilization. Physical examination and knee function according to the Lysholm Knee Scoring Scale were taken at 1-, 6- and 12-week and at 1- and 5-year follow-up. We also compared the redislocation rates. RESULTS: Taping resulted in a significantly better Lysholm score at 6 and 12 weeks post-dislocation (P < 0.05), and also after 5-year follow-up (P < 0.01). Knee function was better at 1-year follow-up. There were no cases of recurrent dislocation. CONCLUSION: Tape bandage immobilization seems superior to a cylinder cast even after 5 years.

Treatment options for mallet finger: a review.

BACKGROUND: Mallet finger is a common injury. The aim of this review is to give an overview of the different treatment options of mallet injuries and their indications, outcomes, and potential complications. METHODS: A literature-based study was conducted using the PubMed database comprising world literature from January of 1980 until January of 2010. The following search terms were used: "mallet" and "finger." RESULTS: There are many variations in the design of splints; there are, however, only a few studies that compare the type of splints with one another. Splinting appears to be effective in uncomplicated and complicated cases. Equal results have been reported for early and delayed splinting therapy. To internally fixate a mallet finger, many different techniques have been reported; however, none of these studies examined their comparisons in a controlled setting. In chronic mallet injuries, a tenodermodesis followed by splinting or a tenotomy of the central slip is usually performed. If pain and impairment persist despite previous surgical corrective attempts, an arthrodesis of the distal interphalangeal joint should be performed. CONCLUSIONS: Uncomplicated cases of mallet injuries are best treated by splinting therapy; cases that do not react to splinting therapy are best treated by surgical interventions. Controversy remains about whether mallet injuries with a larger dislocated bone fragment are best treated by surgery or by external splinting.