KOOS pain as a marker for significant knee pain two and six years after primary ACL reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort study.

OBJECTIVE: The prevalence of radiographic osteoarthritis (OA) after anterior cruciate ligament reconstruction (ACLR) approaches 50%, yet the prevalence of significant knee pain is unknown. We applied three different models of Knee injury and Osteoarthritis Outcome Score (KOOS) thresholds for significant knee pain to an ACLR cohort to identify prevalence and risk factors. DESIGN: Multicenter Orthopaedic Outcomes Network (MOON) prospective cohort patients with a unilateral primary ACLR and normal contralateral knee were assessed at 2 and 6 years. Independent variables included patient demographics, validated Patient Reported Outcomes (PRO; Marx activity score, KOOS), and surgical characteristics. Models included: (1) KOOS criteria for a painful knee = quality of life subscale <87.5 and ≥2 of: KOOSpain <86.1, KOOSsymptoms <85.7, KOOSADL <86.8, or KOOSsports/rec <85.0; (2) KOOSpain subscale score ≤72 (≥2 standard deviations below population mean); (3) 10-point KOOSpain drop from 2 to 6 years. Proportional odds models (alpha ≤ 0.05) were used. RESULTS: 1761 patients of median age 23 years, median body mass index (BMI) 24.8 kg/m(2) and 56% male met inclusion, with 87% (1530/1761) and 86% (1506/1761) follow-up at 2 and 6 years, respectively. At 6 years, n = 592 (39%), n = 131 (9%) and n = 169 (12%) met criteria for models #1 through #3, respectively. The most consistent and strongest independent risk factor at both time-points was subsequent ipsilateral knee surgery. Low 2-year Marx activity score increased the odds of a painful knee at 6 years. CONCLUSIONS: Significant knee pain is prevalent after ACLR; with those who undergo subsequent ipsilateral surgery at greatest risk. The relationship between pain and structural OA warrants further study.

Assessment and management of the painful shoulder.

The shoulder joint is a complex structure composed of intricate bony architecture and an ornate system of muscles, tendons, and ligaments. What many refer to as the "shoulder joint" is actually a combination of 4 articulations--the glenohumeral joint, acromioclavicular joint, sternoclavicular joint, and the scapulothoracic articulation. These structures work together to provide the shoulder complex with multiple degrees of freedom, which allow the upper extremity to be abducted, adducted, rotated, flexed, and extended. Although this flexibility is vital for positioning the arm in space, it can make the evaluation of pathology difficult. Furthermore, neck pathology can refer pain to the shoulder, which may require a screening evaluation of the neck. This article reviews the relevant anatomy and discusses an approach to the differential diagnosis of shoulder pain.

Does intraarticular morphine improve pain control with femoral nerve block after anterior cruciate ligament reconstruction?

In a prospective, randomized, double-blinded manner, we compared the effects of a preoperative intraarticular injection of morphine (5 mg) or a placebo, combined with a postoperative femoral nerve block, on postoperative pain. Sixty-two patients underwent an arthroscopically assisted anterior cruciate ligament reconstruction using patellar tendon autograft under general anesthesia. No statistical difference between the two groups was evident in terms of age, sex, weight, operative time, volume of bupivacaine received with the femoral nerve block, or tourniquet use or tourniquet time. Comparison of visual analog scale pain scores revealed no statistical difference between the groups at any point after the operation. Both groups had a significant decrease in visual analog scale scores after the femoral nerve block, with the lowest mean values 4 hours after the operation (morphine group, 1.7; placebo group, 1.4), and continuing to be significantly less through 24 hours (morphine, 2.6; placebo, 2.9). No significant difference in postoperative narcotic medication use was evident in the recovery room or at home. A post hoc power analysis revealed that the study power reached 87%, with a significance level of 5%. The postoperative femoral nerve block was effective, and intraarticular morphine provided no additional benefit.

Complications of thermal capsulorrhaphy.

As the popularity of thermal capsular shrinkage continues to increase, analysis of complications and failures will continue to provide helpful information in guiding patient selection and decreasing morbidity. Patients who are undergoing revision surgery or who have a history of multiple preoperative dislocations appear to be at higher risk for failure with thermal shrinkage surgery. Caution should be exercised for patients who participate in contact or collision sports, as well as those with MDI. Further study may determine whether thermal shrinkage is most appropriate for microinstability or used as an adjunct to other stabilization procedures.

Meniscal tears in the athlete. Operative and nonoperative management.

There are many factors to consider when treating an active individual with a known or suspected meniscal tear. The athlete with a meniscal tear sometimes can return to competition, temporarily delaying surgery until after the season. If an athlete remains symptomatic and is unable to return, however, then arthroscopic surgery generally is effective to allow the athlete to resume participation. The decision of meniscal repair versus excision must be carefully thought out and discussed with the athlete before surgery. Either treatment can allow the athlete to return to their sport. It is controversial whether or not an athlete should be allowed early return to play after meniscal repair. Further prospective randomized studies would provide useful information in deciding which type of treatment and which type of rehabilitation is best suited for the active individual.

Ketamine sedation for the reduction of children's fractures in the emergency department.

BACKGROUND: There recently has been a resurgence in the utilization of ketamine, a unique anesthetic, for emergency-department procedures requiring sedation. The purpose of the present study was to examine the safety and efficacy of ketamine for sedation in the treatment of children's fractures in the emergency department. METHODS: One hundred and fourteen children (average age, 5.3 years; range, twelve months to ten years and ten months) who underwent closed reduction of an isolated fracture or dislocation in the emergency department at a level-I trauma center were prospectively evaluated. Ketamine hydrochloride was administered intravenously (at a dose of two milligrams per kilogram of body weight) in ninety-nine of the patients and intramuscularly (at a dose of four milligrams per kilogram of body weight) in the other fifteen. A board-certified emergency physician skilled in airway management supervised administration of the anesthetic, and the patients were monitored by a registered nurse. Any pain during the reduction was rated by the orthopaedic surgeon treating the patient according to the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). RESULTS: The average time from intravenous administration of ketamine to manipulation of the fracture or dislocation was one minute and thirty-six seconds (range, twenty seconds to five minutes), and the average time from intramuscular administration to manipulation was four minutes and forty-two seconds (range, sixty seconds to fifteen minutes). The average score according to the Children's Hospital of Eastern Ontario Pain Scale was 6.4 points (range, 5 to 10 points), reflecting minimal or no pain during fracture reduction. Adequate fracture reduction was obtained in 111 of the children. Ninety-nine percent (sixty-eight) of the sixty-nine parents present during the reduction were pleased with the sedation and would allow it to be used again in a similar situation. Patency of the airway and independent respiration were maintained in all of the patients. Blood pressure and heart rate remained stable. Minor side effects included nausea (thirteen patients), emesis (eight of the thirteen patients with nausea), clumsiness (evident as ataxic movements in ten patients), and dysphoric reaction (one patient). No long-term sequelae were noted, and no patients had hallucinations or nightmares. CONCLUSIONS: Ketamine reliably, safely, and quickly provided adequate sedation to effectively facilitate the reduction of children's fractures in the emergency department at our institution. Ketamine should only be used in an environment such as the emergency department, where proper one-on-one monitoring is used and board-certified physicians skilled in airway management are directly involved in the care of the patient.

Brachial neuritis.

Brachial neuritis is a rare disorder of unknown etiology that causes pain and weakness of the shoulder and upper extremity. There have been many descriptions of the disorder in the literature. The classic symptoms begin with an acute onset of sharp pain in the shoulder girdle. As the pain subsides, weakness occurs. The diagnosis often is difficult to make in the acute setting. Diagnostic tests typically are not helpful, although electromyography may be useful. The treatment is chiefly supportive with analgesics initially followed by range of motion exercises. Full functional recovery is expected in most patients, although the interval may be protracted. Understanding the disorder of brachial neuritis and its course will assist in the diagnosis and treatment.

Analgesia with femoral nerve block for anterior cruciate ligament reconstruction.

Anterior cruciate ligament reconstruction is performed routinely as an outpatient surgical procedure despite few studies of patient acceptance or postoperative patient analgesia. This study reports the first series of postoperative femoral nerve blocks as analgesia for outpatient anterior cruciate ligament reconstruction. The authors retrospectively reviewed 161 patients undergoing two incision arthroscopically assisted autograft middle 1/3 patellar tendon anterior cruciate ligament reconstruction on an out-patient basis at the authors' institution during a period of 30 months. Hospital and anesthesia records were reviewed, and 83% of patients were contacted retrospectively to survey their perceptions of the procedure and its outcome. Ninety-eight percent of the patients were discharged from the ambulatory surgery center, with 51% discharged the same day as the surgery and 47% discharged by 7:00 AM the next day. As the study progressed, the number of patients staying overnight was reduced by 50%. Ninety-eight percent of patients surveyed found femoral nerve block to be beneficial, and the same percentage thought the discharge time was appropriate. However, 69% of patients staying overnight cited reasons other than pain as factors in their stay. No significant complications were reported. Based on these results, the administration of a femoral nerve block is recommended for patients undergoing outpatient anterior cruciate ligament reconstruction because it is a highly effective form of analgesia with an excellent degree of patient satisfaction.

Anesthesia and analgesia for the ambulatory management of fractures in children.

The goal of anesthesia in the ambulatory management of fractures in children is to provide analgesia and relieve anxiety in order to facilitate successful closed treatment of the skeletal injury. Numerous techniques short of general anesthesia are available. These methods include blocks (local, regional, and intravenous), sedation (conscious and deep), and dissociative anesthesia (ketamine sedation). Important factors in choosing a particular technique include ease of administration, efficacy, safety, cost, and patient and parent acceptance. Local and regional techniques, such as hematoma, axillary, and intravenous regional blocks, are particularly effective for upper-extremity fractures. Sedation with inhalation agents, such as nitrous oxide, and parenterally administered narcotic-benzodiazepine combinations, are not region-specific and are suitable for patients over a wide range of ages. Ketamine sedation is an excellent choice for children less than 10 years old. With any technique, proper monitoring and adherence to safety guidelines are essential.

Length of operative procedures: reamed femoral intramedullary nailing performed with and without a fracture table.

OBJECTIVES: To determine whether performing reamed intramedullary nailing of the femur without the use of a fracture table decreases the length of operation. DESIGN: Retrospective. SETTING: Level 1 trauma center, Nashville. Tennessee. PATIENTS/PARTICIPANTS: Consecutively treated patients with fractures of the femoral shaft were treated with intramedullary nails from June 1986 to March 1996. INTERVENTION: Reamed intramedullary nailing of the femoral shaft was performed with the use of a fracture table or with the leg draped free on a radiolucent table. MAIN OUTCOME MEASUREMENTS: Length of anesthesia time, prep and drape time (from the point the anesthetized patient is turned over to the surgeons until incision), and intramedullary nailing time (from incision until end of surgery) for reamed intramedullary nailing of the femoral shaft performed with and without the use of a fracture table were compared. RESULTS: Univariate analysis showed statistically significant decreases in the length of prep and drape time, operative time, and anesthetic time when fractures were treated without the use of a fracture table. Multivariate analysis showed that use of a fracture table prolongs prep and drape time (plus twenty minutes), operative time (plus seventeen minutes), and anesthesia time (plus seventy-three minutes) when the covariates of age, sex, fracture location, learning curve, position of the patient, nail brand, and number of distal bolts are controlled. CONCLUSIONS: Reamed intramedullary nailing of the femoral shaft performed without the use of a fracture table is significantly faster than when the procedure is performed with a fracture table.

Dimethyl sulfoxide decreases lung neutrophil sequestration and lung leak.

To investigate basic mechanisms of acute edematous lung injury (adult respiratory distress syndrome), the formylated tripeptide formyl-norleucyl-leucyl-phenylalanine (FNLP) was instilled intratracheally into hamsters. Intratracheal FNLP produced time-dependent and dose-dependent increases in neutrophils recoverable by lung lavage (neutrophil alveolitis) and leak of intravenously injected albumin into the extravascular lung space (lung leak). Treatment with dimethyl sulfoxide (DMSO) decreased (p less than 0.05) neutrophil alveolitis and lung leak in hamsters given FNLP intratracheally. The effect of DMSO on various neutrophil functions was also studied in vitro. Addition of DMSO at concentrations (about 0.20%) measured in plasma of hamsters given DMSO decreased (p less than 0.05) neutrophil chemotaxis but not neutrophil superoxide anion generation or adherence to cultured endothelial cell monolayers or nylon fiber in vitro. We conclude that intratracheal FNLP causes neutrophil alveolitis and lung leak and that DMSO treatment ameliorates these processes, possibly by inhibiting neutrophil chemotaxis.

Human serum catalase decreases endothelial cell injury from hydrogen peroxide.

Serum from normal human subjects contained variable amounts of catalase activity, which was inhibitable by heat, azide, trichloroacetic acid (TCA), or aminotriazole treatment. Serum also decreased hydrogen peroxide (H2O2) concentrations in vitro and H2O2-mediated injury to cultured endothelial cells. By comparison, heat-, azide-, TCA-, or aminotriazole-treated serum neither decreased H2O2 concentrations in vitro nor reduced H2O2-mediated damage to endothelial cells. We conclude that serum catalase activity can alter H2O2-dependent reactions. We speculate that variations in serum catalase activity may alter individual susceptibility to oxidant-mediated vascular disease or be a factor when added to test systems in vitro.