Lower-Dose Mepivacaine Plus Fentanyl May Improve Spinal Anesthesia for Knee Arthroscopy.

BACKGROUND: Previous work indicates that 30 mg isobaric mepivacaine 1.5% plus 10 µg fentanyl produces reliable anesthesia for knee arthroscopy with a more rapid recovery profile than 45 mg mepivacaine. QUESTIONS/PURPOSES: This randomized controlled trial compared plain mepivacaine to three reduced doses of mepivacaine with 10 µg fentanyl for spinal anesthesia. METHODS: Following written informed consent, subjects undergoing outpatient knee arthroscopy were prospectively randomized into one of four groups: mepivacaine 37.5 mg (M37.5); mepivacaine 30 mg plus fentanyl 10 µg (M30/F10); mepivacaine 27 mg plus fentanyl 10 µg (M27/F10); and mepivacaine 24 mg plus fentanyl 10 µg (M24/F10). The spinal was evaluated by the blinded anesthetist and surgeon. In the post-anesthesia care unit, sensory and motor block resolution was assessed. Subjects rated their satisfaction with the overall experience. RESULTS: Group M30/F10 (n = 6) had two "fair" anesthetics, and group M27/F10 (n = 10) had one "fair" and one "inadequate" anesthetic. Both groups were eliminated from further enrollment per study protocol. The recovery profiles showed little difference between groups M37.5 and M30/F10, except for motor block resolution (median (25th percentile, 75th percentile): 171 (135, 195) and 128 (120, 135), respectively). Groups M27/F10 and M24/F10 demonstrated recovery profiles that were faster than group M37.5. Patient satisfaction was 10/10 for all groups. CONCLUSIONS: Adding fentanyl 10 µg to a lower dose of mepivacaine 1.5% can lead to quicker recovery profiles. However, this advantage of a quicker recovery must be weighed against the likelihood of an incomplete anesthetic.

Periprosthetic patellar fracture after an open knee dislocation.

We present a patient who sustained an open knee dislocation with a periprosthetic fracture of the patella and who was treated satisfactorily with tension band wiring and a conservative rehabilitation program. In addition to describing this unique combination of injuries, we review the literature on the treatment of periprosthetic patellar fractures. Although internal fixation of these fractures historically has provided unpredictable results, we think that it is warranted if the patella has adequate bone stock.

Management of early deep infection after rotator cuff repair surgery.

Deep soft-tissue infection occurs infrequently after rotator cuff repair surgery. We retrospectively reviewed the clinical presentation in 14 patients whose rotator cuff repair was complicated by an early deep infection (<6 weeks). The functional outcome after treatment in 12 of these patients was analyzed at a mean follow-up of 37.5 months (range, 11-122 months). The diagnosis of infection was most often made within 3 weeks from the date of surgery (mean, 18 days; range, 3-41 days). Common presenting symptoms included localized wound erythema and drainage. The blood leukocyte counts were usually normal, but the erythrocyte sedimentation rates and C-reactive protein levels were elevated. A mean of 2.6 surgical debridements were required to clean the wound effectively in each case. Eight of twelve patients were dissatisfied at final assessment. Most patients reported reasonably good relief of pain, but they had residual shoulder stiffness and weakness. Retention of suture anchors in the humeral head did not preclude successful eradication of the infection.

Negative prognostic factors in managing massive rotator cuff tears.

OBJECTIVE: To investigate the negative prognostic factors in the management of massive rotator cuff tears. DESIGN: Retrospective nonrandomized study. SETTING: Faculty Practice associated with a major orthopedic teaching hospital. PATIENTS: 108 patients who were treated for massive rotator cuff tears were evaluated for an average of 3.2 years posttreatment. There were 58 females and 50 males, with a mean age of 61.3 years. INTERVENTIONS: 40 patients underwent conservative nonsurgical management (Group 1), 32 patients underwent arthroscopic debridement (Group 2), and 36 patients underwent primary repair of the rotator cuff (Group 3). MAIN OUTCOME MEASURES: A detailed Shoulder Rating Questionnaire was filled out by patients pretreatment and minimal 2 years posttreatment. RESULTS: Overall, Group 1 had 65% excellent or good outcomes, Group 2 had 81%, and Group 3 had 86%. The subgroup of patients in Group 1 who had cortisone injections had a 75% success rate. CONCLUSIONS: Negative prognostic factors evaluated are presence of glenohumeral arthritis, decreased passive range of motion, superior migration of the humeral head, presence of atrophy, and external rotation/abduction strength less than 3. The presence of 3 or more of these negative prognostic factors are correlated with poor outcomes in the treatment of massive rotator cuff tears.