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Su P, Zhang L, Zhu Y, Li J, Fu W. Most Analgesia Treatments Have No Clinical Significance for Anterior Cruciate Ligament Reconstruction: A Network Meta-analysis of 66 Randomized Controlled Trials. Arthroscopy 2022; 38:1326-1340.e0. [PMID: 34454059 DOI: 10.1016/j.arthro.2021.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/14/2021] [Accepted: 08/14/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE To assess the relative efficacy of several clinical treatments for postoperative analgesia of anterior cruciate ligament reconstruction through network meta-analysis based on multiple published randomized controlled trials. METHODS We searched PubMed, the Cochrane library, EMBASE, and Web of Science, each from inception until February 15, 2021. Outcomes including pain scores at rest (visual analog scale, numerical rating scales, and other scales, which were converted to a standardized 0-10 scale), morphine consumption, and complications were meta-analyzed. Quality of the included studies was assessed using the Cochrane risk-of-bias tool. The authors defined the best choice for postoperative analgesia as the one that had significant difference in pain scores, morphine consumption, and had no significant difference in the risk of complications compared with placebo in the initial 48 postoperative hours. RESULTS In total, 66 studies with 4,168 patients were included in this network meta-analysis. Only periarticular infiltration was significantly superior to placebo in pain scores and morphine consumption (pain at 2 hours: mean difference [MD] -0.74, 95% confidence interval [CI] -1.36 to -0.12; pain at 6 hours: MD -0.81, 95% CI -1.42 to -0.21; pain at 12 hours: MD -0.85, 95% CI -1.53 to -0.17; pain at 24 hours: MD -0.80, 95% CI -1.19 to -0.40; morphine consumption at 24 hours: MD -10.12, 95% CI -14.31 to -5.93; morphine consumption at 48 hours: MD -5.62, 95% CI -6.74 to -4.51). Periarticular infiltration did not increase the risk of complications compared with placebo (nausea and vomiting: odds ratio [OR] 0.63, 95% CI 0.34-1.16; pruritus: OR 0.74, 95% CI 0.35-1.58; urinary retention: OR 0.55, 95% CI 0.25-1.23). In addition, There was no significant difference between adductor canal block and femoral nerve block in pain scores and morphine consumption (pain at 2 hours: MD -0.01, 95% CI -1.44 to 1.42; pain at 6 hours: MD 0.29, 95% CI -0.28 to 0.86; pain at 12 hours: MD 0.36, 95% CI -0.44 to 1.16; pain at 24 hours: MD 0.26, 95% CI -0.22 to 0.75; pain at 48 hours: MD -0.36, 95% CI -0.97 to 0.24; morphine at 24 hours: MD 1.04, 95% CI -4.70 to 6.79; morphine at 48 hours: MD -0.32, 95% CI -0.70 to 0.07; postoperative nausea and vomiting: OR 1.07, 95% CI 0.55-2.09; pruritus: OR 1.36, 95% CI 0.66-2.79; urinary retention: OR 1.41, 95% CI 0.37-5.29). CONCLUSIONS Based on current evidence, most analgesic methods could result in lower pain scores and decrease morphine consumption when compared with placebo; however, differences between methods were small and inconsistent. There seemed to be no significant difference between adductor canal block and femoral nerve block in pain score, morphine consumption and complications. LEVEL OF EVIDENCE Level I, meta-analysis of Level I RCTs.
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Affiliation(s)
- Peng Su
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Zhang
- School of Finance, Qilu University of Technology, Jinan, China
| | - Yanlin Zhu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jian Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Weili Fu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, China.
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Kunze KN, Polce EM, Ranawat AS, Randsborg PH, Williams RJ, Allen AA, Nwachukwu BU, Pearle A, Stein BS, Dines D, Kelly A, Kelly B, Rose H, Maynard M, Strickland S, Coleman S, Hannafin J, MacGillivray J, Marx R, Warren R, Rodeo S, Fealy S, O'Brien S, Wickiewicz T, Dines JS, Cordasco F, Altcheck D. Application of Machine Learning Algorithms to Predict Clinically Meaningful Improvement After Arthroscopic Anterior Cruciate Ligament Reconstruction. Orthop J Sports Med 2021; 9:23259671211046575. [PMID: 34671691 PMCID: PMC8521431 DOI: 10.1177/23259671211046575] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/23/2021] [Indexed: 12/17/2022] Open
Abstract
Background: Understanding specific risk profiles for each patient and their propensity to experience clinically meaningful improvement after anterior cruciate ligament reconstruction (ACLR) is important for preoperative patient counseling and management of expectations. Purpose: To develop machine learning algorithms to predict achievement of the minimal clinically important difference (MCID) on the International Knee Documentation Committee (IKDC) score at a minimum 2-year follow-up after ACLR. Study Design: Case-control study; Level of evidence, 3. Methods: An ACLR registry of patients from 27 fellowship-trained sports medicine surgeons at a large academic institution was retrospectively analyzed. Thirty-six variables were tested for predictive value. The study population was randomly partitioned into training and independent testing sets using a 70:30 split. Six machine learning algorithms (stochastic gradient boosting, random forest, neural network, support vector machine, adaptive gradient boosting, and elastic-net penalized logistic regression [ENPLR]) were trained using 10-fold cross-validation 3 times and internally validated on the independent set of patients. Algorithm performance was assessed using discrimination, calibration, Brier score, and decision-curve analysis. Results: A total of 442 patients, of whom 39 (8.8%) did not achieve the MCID, were included. The 5 most predictive features of achieving the MCID were body mass index ≤27.4, grade 0 medial collateral ligament examination (compared with other grades), intratunnel femoral tunnel fixation (compared with suspensory), no history of previous contralateral knee surgery, and achieving full knee extension preoperatively. The ENPLR algorithm had the best relative performance (C-statistic, 0.82; calibration intercept, 0.10; calibration slope, 1.15; Brier score, 0.068), demonstrating excellent predictive ability in the study’s data set. Conclusion: Machine learning, specifically the ENPLR algorithm, demonstrated good performance for predicting a patient’s propensity to achieve the MCID for the IKDC score after ACLR based on preoperative and intraoperative factors. The femoral tunnel fixation method was the only significant intraoperative variable. Range of motion and medial collateral ligament integrity were found to be important physical examination parameters. Increased body mass index and prior contralateral surgery were also significantly predictive of outcome.
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Affiliation(s)
- Kyle N Kunze
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Evan M Polce
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Anil S Ranawat
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Per-Henrik Randsborg
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Riley J Williams
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Answorth A Allen
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Benedict U Nwachukwu
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | | | - Andrew Pearle
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Beth S Stein
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - David Dines
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Anne Kelly
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Bryan Kelly
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Howard Rose
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Michael Maynard
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Sabrina Strickland
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Struan Coleman
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Jo Hannafin
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - John MacGillivray
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Robert Marx
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Russell Warren
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Scott Rodeo
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Stephen Fealy
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Stephen O'Brien
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Thomas Wickiewicz
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Joshua S Dines
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - Frank Cordasco
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
| | - David Altcheck
- Division of Sports Medicine, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,All authors are listed in the Authors section at the end of this article.,Investigation performed at the Hospital for Special Surgery, New York, New York, USA
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Criss CR, Melton MS, Ulloa SA, Simon JE, Clark BC, France CR, Grooms DR. Rupture, reconstruction, and rehabilitation: A multi-disciplinary review of mechanisms for central nervous system adaptations following anterior cruciate ligament injury. Knee 2021; 30:78-89. [PMID: 33873089 DOI: 10.1016/j.knee.2021.03.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/18/2021] [Accepted: 03/18/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite surgical reconstruction and extensive rehabilitation, persistent quadriceps inhibition, gait asymmetry, and functional impairment remain prevalent in patients after anterior cruciate ligament (ACL) injury. A combination of reports have suggested underlying central nervous system adaptations in those after injury govern long-term neuromuscular impairments. The classic assumption has been to attribute neurophysiologic deficits to components of injury, but other factors across the continuum of care (e.g. surgery, perioperative analgesia, and rehabilitative strategies) have been largely overlooked. OBJECTIVE This review provides a multidisciplinary perspective to 1) provide a narrative review of studies reporting neuroplasticity following ACL injury in order to inform clinicians of the current state of literature and 2) provide a mechanistic framework of neurophysiologic deficits with potential clinical implications across all phases of injury and recovery (injury, surgery, and rehabilitation) RESULTS: Studies using a variety of neurophysiologic modalities have demonstrated peripheral and central nervous system adaptations in those with prior ACL injury. Longitudinal investigations suggest neurophysiologic changes at spinal-reflexive and corticospinal pathways follow a unique timecourse across injury, surgery, and rehabilitation. CONCLUSION Clinicians should consider the unique injury, surgery, anesthesia, and rehabilitation on central nervous system adaptations. Therapeutic strategies across the continuum of care may be beneficial to mitigate maladaptive neuroplasticity in those after ACL injury.
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Affiliation(s)
- Cody R Criss
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA.
| | - M Stephen Melton
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Sergio A Ulloa
- OhioHealth Physician Group Heritage College: Orthopedic and Sports Medicine, OhioHealth O'Bleness Memorial Hospital, Athens, OH, USA
| | - Janet E Simon
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA; Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions, Ohio University, Athens, OH, USA
| | - Brian C Clark
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA; Department of Biomedical Sciences, Ohio University, Athens, OH, USA
| | - Christopher R France
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA; Department of Psychology, College of Arts and Sciences, Ohio University, Athens, OH, USA
| | - Dustin R Grooms
- Ohio Musculoskeletal and Neurological Institute, Ohio University, Athens, OH, USA; Division of Athletic Training, School of Applied Health Sciences and Wellness, College of Health Sciences and Professions, Ohio University, Athens, OH, USA; Division of Physical Therapy, School of Rehabilitation and Communication Sciences, College of Health Sciences and Professions, Ohio University, Athens, OH, USA
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Scher M, Cabrera CI, Cai Y, Tamaki A, Li S, Fowler N, Rezaee R, Lavertu P, Teknos T, Thuener J. Outpatient Parotidectomy, a Safety and Financial Review. Ann Otol Rhinol Laryngol 2021:34894211016714. [PMID: 33980056 DOI: 10.1177/00034894211016714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective of this study is to investigate the safety, efficacy, and potential cost-savings of the outpatient parotidectomy procedure. METHODS This is a retrospective chart review of all patients who underwent a parotidectomy at a large academic center from 2015 through 2019 including demographic data, postoperative complications, drain placement, readmission, and financial cost. A comparison was performed between patients who underwent an outpatient vs inpatient parotidectomy. RESULTS A total of 335 patients underwent parotidectomy (136 outpatient; 199 inpatient). Comparison of patient demographics, common comorbidities, tumor size, tumor type, postoperative complications, and readmission rate was similar between the inpatient and outpatient cohorts. The overall mean cost difference between inpatient parotidectomy and outpatient parotidectomy for all years was $1528.58 (95%CI: $1139-$1916). CONCLUSION The outpatient parotidectomy procedure has a comparable safety profile to the inpatient procedure while providing a significant cost-savings benefit.
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Affiliation(s)
- Maxwell Scher
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Claudia I Cabrera
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Yida Cai
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Akina Tamaki
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Shawn Li
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Nicole Fowler
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rod Rezaee
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Pierre Lavertu
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Theodoros Teknos
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jason Thuener
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Kuršumović K, Charalambous CP. Relationship of Graft Type and Vancomycin Presoaking to Rate of Infection in Anterior Cruciate Ligament Reconstruction. JBJS Rev 2020; 8:e1900156. [DOI: 10.2106/jbjs.rvw.19.00156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Young age, female gender, Caucasian race, and workers' compensation claim are risk factors for reoperation following arthroscopic ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2020; 28:2213-2223. [PMID: 31813020 DOI: 10.1007/s00167-019-05798-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/12/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Given the increasing incidence of arthroscopic anterior cruciate ligament reconstruction (ACLR), mid- to long-term rates of reoperations were investigated on the ipsilateral knee following ACLR. METHODS New York Statewide Planning and Research Cooperative Systems (SPARCS) database was queried from 2003 to 2012 to identify patients with a primary ICD-9 diagnosis for ACL tear and concomitant CPT code for ACLR. Patients were longitudinally followed for at least 2 years to determine incidence and nature of subsequent ipsilateral knee procedures. RESULTS The inclusion criteria were met by 45,231 patients who had undergone ACLR between 2003 and 2012. Mean age was found to be 29.7 years (SD 11.6). Subsequent ipsilateral outpatient knee surgery after a mean of 25.7 ± 24.5 months was performed in 10.7% of patients. Revision ACLR was performed for nearly one-third of reoperations. Meniscal pathology was addressed in 58% of subsequent procedures. Age 19 or younger, female gender, worker's compensation (WC) insurance, and Caucasian race were identified as independent risk factors for any ipsilateral reoperation. An initial isolated ACLR and initial ACLR performed by a high-volume surgeon were found to be independently associated with lower reoperation rates. Tobacco use was not significant. Survival rates of 93.4%, 89.8% and 86.7% at 2-, 5- and 10 years, respectively, were found for any ipsilateral reoperation. CONCLUSION A 10.7% ipsilateral reoperation rate at an average of 25.9 (SD 24.5) months after ACLR and an overall ACLR revision rate of 3.1% were demonstrated by the analysis. Meniscal pathology was addressed in the majority of subsequent interventions. Age 19 or younger, female gender, Caucasian race, and WC claim were associated with reoperation. Initial isolated ACLR and procedure performed by high-volume surgeon were associated with reduced reoperation. LEVEL OF EVIDENCE Level III.
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Liu H, Lu W, Liang D, Geng H, Zhu W, Ouyang K, Li H, Peng L, Feng W, Zhong M, Chen K, Li Y, Deng Z, Wang D. [Effect of isokinetic training of thigh muscle group on graft remodeling after anterior cruciate ligament reconstruction]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1088-1094. [PMID: 31512448 DOI: 10.7507/1002-1892.201902059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective To investigate the effect of isokinetic training of thigh muscle group on graft remodeling after anterior cruciate ligament (ACL) reconstruction, and summarize the relevant rules to guide the clinic. Methods Between August 2016 and December 2016, forty patients underwent arthroscopic ACL reconstruction using hamstring tendon were randomly divided into isokinetic group and control group ( n=20). The two groups of patients underwent staged rehabilitation treatment. The isokinetic group replaced the traditional intervention with the corresponding isokinetic strength training from 3 to 6 months after operation, and the traditional rehabilitation intervention was used in the control group. Finally, 12 cases of isokinetic group and 12 cases of control group with complete follow-up were enrolled in study. There was no significant difference in gender, age, body mass index, side of injury, the interval between injury and operation, and preoperative International Knee Documentation Committee (IKDC) score between the two groups ( P>0.05). The peak torque (PT) of knee extension and flexion and hamstring quadriceps ratio (H/Q) were measured at 3 months, 6 months, 12 months, and the second-look arthroscopy. The MRI examination was performed at the same time to evaluate graft remodeling. The shape, tension, and degree of vascularization of grafts were observed under arthroscopy. The grafts were harvested and observed by HE staining. Results The invertal between ACL reconstruction and the second-look arthroscopy was (23.57±3.23) months in isokinetic group and (23.22±3.56) months in control group, showing no significant difference between the two groups ( P>0.05). At the second-look arthroscopy, the IKDC score was 90.45±4.73 in isokinetic group and 89.32±4.54 in control group, showing significant differences when compared with preoperative scores in the two groups ( P<0.05). But there was no significant difference between the two groups ( t=0.868, P=0.404). At 3 months after operation, there was no significant difference in the PT of knee extension and flexion between the two groups ( P>0.05). At 6 months, 12 months, and the second-look arthroscopy, the PT of knee extension and flexion in isokinetic group were higher than those in control group ( P<0.05). The H/Q at 6 months and 12 months were higher in isokinetic group than in control group, and the differences were significant ( P<0.05). There was no significant difference in MRI score between the two groups at 3 months, 6 months, and the second-look arthroscopy ( P>0.05). The MRI score at 12 months was significantly higher in isokinetic group than in control group ( P<0.05). At the second-look arthroscopy, there was no significant difference in the arthroscopic score between the two groups ( P>0.05), and the histological score of the isokinetic group was superior to the control group ( P<0.05). Conclusion On the basis of regular rehabilitation training, using the isokinetic training system to develop a suitable post-surgical isokinetic rehabilitation training program is helpful in early muscle strength recovery, early graft remodeling, and even long-term histological results after ACL reconstruction.
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Affiliation(s)
- Haifeng Liu
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Wei Lu
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000,
| | - Daqiang Liang
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Hongli Geng
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Weimin Zhu
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Kan Ouyang
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Hao Li
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Liangquan Peng
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Wenzhe Feng
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Mingjin Zhong
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Kang Chen
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Ying Li
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Zhenhan Deng
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000, P.R.China
| | - Daping Wang
- Department of Sports Medicine, the First Affiliated Hospital of Shenzhen University (Shenzhen Second People's Hospital), Shenzhen Guangzhou, 518000, P.R.China;Sports Medicine Engineering Technology Research Center of Guangdong Province, Shenzhen Guangdong, 518000,
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Jansson H, Narvy SJ, Mehran N. Perioperative Pain Management Strategies for Anterior Cruciate Ligament Reconstruction. JBJS Rev 2018. [DOI: 10.2106/jbjs.rvw.17.00059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Ferrari D, Lopes TJA, França PFA, Azevedo FM, Pappas E. Outpatient versus inpatient anterior cruciate ligament reconstruction: A systematic review with meta-analysis. Knee 2017; 24:197-206. [PMID: 28117216 DOI: 10.1016/j.knee.2017.01.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 10/27/2016] [Accepted: 01/04/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Efforts to reduce the financial costs related to anterior cruciate ligament reconstruction (ACLR) include reducing the length of hospitalization of the patient undergoing ACLR. However, it is unclear if inpatient and outpatient ACLR differ in terms of safety, satisfaction, costs and clinical outcomes. AIM To systematically review and synthesize the literature that directly compared costs and outcomes after outpatient and inpatient ACLR. METHODS Studies that directly compared outcomes of inpatient and outpatient ACLR were retrieved via searches in MEDLINE, EMBASE, CINAHL, AMED, Cochrane, SPORTDiscus, Web of Science and SCOPUS databases. Random effects meta-analysis and descriptive analysis were performed for relevant outcomes. RESULTS Costs analysis suggests that outpatient ACLR may be a cost effective procedure with savings ranging from $1371 to $7390. There were no differences for systemic and local complications p=0.64 (odds ratio 1.65, 95% confidence interval 0.20 to 13.49) and p=0.72 (0.81, 0.26 to 2.56) respectively, or pain in the second and seventh days after surgery, p=0.78 (mean difference -0.16; 95% confidence interval -1.28 to 0.96) and p=0.44 (0.48, -0.75 to 1.71), respectively. However, the outpatient group had less pain than the inpatient group in the first and third days after surgery, p=0.0001 (-0.39, -0.57 to -0.21) and p=0.0001(-0.39, -0.39 to -0.20), respectively. Descriptive analysis revealed that the outpatient group experienced similar or better satisfaction, strength and knee function compared to the inpatient group. CONCLUSION AND KEY FINDINGS Complications, pain, satisfaction, knee function and strength are similar or better after outpatient compared to inpatient ACLR. Furthermore, cost savings may be achieved with outpatient ACLR. However, included studies presented low methodological quality and the quality of evidence was very low, so these results need to be confirmed by future studies. REGISTRATION NUMBER PROSPERO (CRD42015024990).
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Affiliation(s)
- Deisi Ferrari
- University of São Paulo, Post-Graduation Program Interunits Bioengineering EESC/FMRP/IQSC-USP, São Carlos, Brazil; CAPES Foundation, Ministry of Education of Brazil, Brasília, DF 70.040-020, Brazil.
| | - Thiago J A Lopes
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia; Research Laboratory of Exercise Science, The Brazilian Navy, Rio de Janeiro, Brazil.
| | - Paulo F A França
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
| | - Fábio M Azevedo
- University of São Paulo State, School of Science and Technology, Physical Therapy Department, Presidente Prudente, Brazil.
| | - Evangelos Pappas
- Discipline of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia.
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10
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Buescu CT, Onutu AH, Lucaciu DO, Todor A. Pain level after ACL reconstruction: A comparative study between free quadriceps tendon and hamstring tendons autografts. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2017; 51:100-103. [PMID: 28242265 PMCID: PMC6197319 DOI: 10.1016/j.aott.2017.02.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Revised: 05/12/2016] [Accepted: 09/02/2016] [Indexed: 12/30/2022]
Abstract
Objective The objective of this study was to compare the pain levels and analgesic consumption after single bundle ACL reconstruction with free quadriceps tendon autograft versus hamstring tendon autograft. Patients and methods A total of 48 patients scheduled for anatomic single-bundle ACL reconstruction were randomized into two groups: the free quadriceps tendon autograft group (24 patients) and the hamstring tendons autograft group (24 patients). A basic multimodal analgesic postoperative program was used for all patients and rescue analgesia was provided with tramadol, at pain scores over 30 on the Visual Analog Scale. The time to the first rescue analgesic, the number of doses of tramadol and pain scores were recorded. The results within the same group were compared with the Wilcoxon signed test. Results Supplementary analgesic drug administration proved significantly higher in the group of subjects with hamstring grafts, with a median (interquartile range) of 1 (1.3) dose, compared to the group of subjects treated with a quadriceps graft, median = 0.5 (0.1.25) (p = 0.009). A significantly higher number of subjects with a quadriceps graft did not require any supplementary analgesic drug (50%) as compared with subjects with hamstring graft (13%; Z-statistics = 3.01, p = 0.002). The percentage of subjects who required a supplementary analgesic drug was 38% higher in the HT group compared with the FQT group. Conclusion The use of the free quadriceps tendon autograft for ACL reconstruction leads to less pain and analgesic consumption in the immediate postoperative period compared with the use of hamstrings autograft. Level of Evidence Level I Therapeutic study
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Affiliation(s)
- Cristian Tudor Buescu
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Orthopedics, Traumatology and Pediatric Orthopedics, Cluj Napoca, Cluj, Romania
| | - Adela Hilda Onutu
- Cluj Emercency County Clinical Hospital, Anesthesiology Department of Orthopedics Clinic, Cluj Napoca, Romania
| | - Dan Osvald Lucaciu
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Orthopedics, Traumatology and Pediatric Orthopedics, Cluj Napoca, Cluj, Romania
| | - Adrian Todor
- Iuliu Hatieganu University of Medicine and Pharmacy, Department of Orthopedics, Traumatology and Pediatric Orthopedics, Cluj Napoca, Cluj, Romania.
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Hulet C, Rochcongar G, Court C. Developments in ambulatory surgery in orthopedics in France in 2016. Orthop Traumatol Surg Res 2017; 103:S83-S90. [PMID: 28057478 DOI: 10.1016/j.otsr.2016.11.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 11/04/2016] [Accepted: 11/04/2016] [Indexed: 02/02/2023]
Abstract
Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full hospital admission by AS is now well established and recognized. Health-care centers have learned, in coordination with the medico-surgical and paramedical teams, how to set up AS units and the corresponding clinical pathways. There is no single model handed down from above. The authorities have encouraged these developments, partly by regulations but also by means of financial incentives. Patient eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder, foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attractiveness of AS for surgeons. More than ever, it is the patient who is "ambulatory", within an organized structure in which surgical technique and pain management are well controlled. Not all patients can be eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical and surgical prescription.
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Affiliation(s)
- C Hulet
- Département de chirurgie orthopédique et traumatologique, niveau 11, Inserm U1075 COMETE « mobilité : attention, orientation & chronobiologie », université de Caen Basse-Normandie, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France.
| | - G Rochcongar
- Département de chirurgie orthopédique et traumatologique, niveau 11, Inserm U1075 COMETE « mobilité : attention, orientation & chronobiologie », université de Caen Basse-Normandie, CHU de Caen, avenue de la Côte-de-Nacre, 14033 Caen cedex, France
| | - C Court
- Orthopédie TRaumatologie, hôpital Kremlin-Bicêtre, hôpitaux universitaires Paris Sud, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
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French prospective multicenter comparative assessment of ambulatory surgery feasibility in anterior cruciate ligament reconstruction. Orthop Traumatol Surg Res 2016; 102:S257-S263. [PMID: 27687062 DOI: 10.1016/j.otsr.2016.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/20/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The main objective of this multicenter study was to assess the feasibility of ambulatory surgery in France in anterior cruciate ligament (ACL) reconstructions for any technique or graft used (hamstring, patellar tendon, fascia lata). We hypothesized that a dedicated organization would guarantee the patient's safety. PATIENTS AND METHODS A multicenter, non-randomized, prospective, comparative study, conducted within the SFA symposium was conducted between January 2014 and March 2015, included all the patients operated on for arthroscopic ACL reconstruction using different surgical techniques. The outpatient group (OP) included patients eligible for day surgery who provided informed consent; the conventional hospitalization group (CH) comprised patients declined for outpatient surgery for organizational reasons. The main outcome was failure of the admission mode defined by hospitalization of a patient undergoing outpatient surgery or rehospitalization within the 1st week after discharge. The secondary outcomes were assessment of pain and postoperative complications. A total of 1076 patients were studied with 680 in the OP group and 396 in the CH group. The mean age was 30years±9years. In the CH group, the mean hospital stay was 2.7±0.8days. RESULTS Twenty-three OP patients were hospitalized or rehospitalized (3.4%). Thirty-six (5.2%) early postoperative complications were noted in the OP group and 17 (4.3%) in the CH group (non-significant difference). Mean postoperative pain on D0-D4 and satisfaction were comparable between the two groups. CONCLUSION This prospective multicenter study observed no serious incidents. In a selected population, the risks are comparable to those of conventional hospitalization. Outpatient ACL surgery is therefore feasible in France in 2016. LEVEL OF PROOF III: case-control study.
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Baverel L, Cucurulo T, Lutz C, Colombet, Cournapeau J, Dalmay F, Lefevre N, Letartre R, Potel JF, Roussignol X, Surdeau L, Servien E. Anesthesia and analgesia methods for outpatient anterior cruciate ligament reconstruction. Orthop Traumatol Surg Res 2016; 102:S251-S255. [PMID: 27687059 DOI: 10.1016/j.otsr.2016.08.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/20/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION More and more anterior cruciate ligament (ACL) reconstructions are being performed as outpatient surgery in France, because of economic considerations. Postoperative pain is the most common reason for delayed discharge that could require hospitalization, and the main reason for unanticipated hospital admission. The purpose of this study was to define the best anesthesia and analgesia methods for ACL reconstruction. MATERIALS AND METHODS This was a prospective, multicenter, comparative study performed between January 2014 and April 2015. Inclusion criteria were ACL reconstruction in patients above 15 years of age performed as an outpatient surgical procedure. The anesthesia techniques analyzed were general anesthesia, spinal anesthesia and quadruple nerve blockade. The analgesic methods studied were single-shot nerve blocks, continuous nerve blocks, peri-articular and intra-articular local infiltration analgesia (LIA), non-steroidal anti-inflammatory agents (NSAIDs) and intravenous corticosteroids. The main outcome criterion was pain on a visual analog scale (VAS). The secondary outcome criteria were delayed discharge of a patient who had undergone outpatient surgery, consumption of opioids and complications for the various anesthesia techniques and analgesia methods. RESULTS In all, 680 patients were included in this study, which was 63% of the ACL reconstruction procedures performed during this period. The study population was 69% male and 31% female, with an average age of 30 years. Twenty-three patients (3.4%) could not be discharged on the day of surgery. No correlation was found with the anesthesia technique used. NSAID treatment was protective relative to delayed discharge (P=0.009), while opioid consumption was a risk factor (P<0.01). There were no differences in the pain levels related to the type of anesthesia. Peri-articular LIA of the hamstring tendon harvest site was effective. Intra-articular LIA did not provide better analgesia. Continuous nerve block had complication rates above 13%. DISCUSSION All types of anesthesia were compatible with outpatient ACL reconstruction. No gold standard analgesia method can be defined based on this study's findings. However, we recommend multimodal analgesia associating peri-articular LIA or one-shot sensory saphenous nerve block, NSAIDs and corticosteroid treatment, and cryotherapy. LEVEL OF EVIDENCE II, prospective comparative non-randomized study.
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Affiliation(s)
- L Baverel
- Centre hospitalier universitaire, Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes, France.
| | - T Cucurulo
- Institut de Chirurgie Orthopédique et Sportive (ICOS 13), 463, rue Paradis, 13008 Marseille, France
| | - C Lutz
- ICOSS, 50, avenue des Vosges, 67000 Strasbourg, France
| | - Colombet
- Centre de Chirurgie Orthopédique et Sportive, 2, rue Negrevergne, 33700 Mérignac, France
| | - J Cournapeau
- Centre hospitalier universitaire, Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - F Dalmay
- Inserm 1094, UMR, NET, 2, rue du Docteur-Marcland, 87025 Limoges, France
| | - N Lefevre
- Institut de l'Appareil Locomoteur Nollet, 75017 Paris, France; Clinique du Sport Paris V, 75005 Paris, France
| | - R Letartre
- Hôpital privé la Louvière, 122, rue de la Louvière, 59000 Lille, France
| | - J-F Potel
- Medipôle, 45, rue de Gironis, 31036 Toulouse, France
| | - X Roussignol
- Centre hospitalier universitaire, Ch.-Nicolle, 76031 Rouen, France
| | - L Surdeau
- Centre de Chirurgie Orthopédique et Sportive, 2, rue Negrevergne, 33700 Mérignac, France
| | - E Servien
- Hopital universitaire de la croix-rousse, Centre Albert-Trillat, 103, grande rue de la Croix-Rousse, 69004 Lyon, France
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Pain after out-patient vs. in-patient ACL reconstruction: French prospective study of 1076 patients. Orthop Traumatol Surg Res 2016; 102:S265-S270. [PMID: 27687061 DOI: 10.1016/j.otsr.2016.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 08/20/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anterior cruciate ligament (ACL) repair is increasingly performed on an out-patient basis. In France, however, concern about post-operative pain remains a strong barrier to out-patient ACL repair. The primary objective of this study was to compare post-operative pain after ACL repair as out-patient versus in-patient surgery. The secondary objectives were to assess the time-course of post-operative pain and to identify factors associated with pain intensity. MATERIAL AND METHODS A multicentre, prospective, comparative, non-randomised study was conducted in France for the French Society for Arthroscopy (SFA) symposium. Patients who underwent primary ACL repair between January 2014 and March 2015 were included if they were eligible for out-patient surgery. The choice between out-patient and in-patient surgery was based on organisational and logistical considerations. Pain intensity was self-evaluated by the patients using a visual analogue scale (VAS), pre-operatively then in the evening after surgery, during the night after surgery, and 1, 3, and 5 days after surgery. The patients performed the evaluations at home using websurvey.fr® software. Demographic data, the characteristics of the surgical procedure, and the IKDC and Lysholm scores before and after surgery were collected. RESULTS Of the 1076 patients included in the study, 680 had out-patient surgery and 396 in-patient surgery. Mean age was 30±9 years. The two groups were comparable at baseline. Pain intensity was not significantly different between the two groups at any of the measurement time points. Pain intensity showed a peak on post-operative day 1 that was similar in the two groups. The initial post-operative pain intensity score predicted subsequent pain intensity: patients with VAS scores <2 on the day of surgery also had low pain scores after surgery. In both groups, factors associated with greater pain intensity were age <25 years, high pre-operative pain score, and surgery performed after noon. Neither surgical technique nor concomitant lesions and methods used to treat them were associated with pain intensity. Risk factors for severe post-operative pain (VAS score >7) in the out-patient group were younger age, female gender, pre-operative VAS score >3, and tourniquet time >50minutes. CONCLUSION Pain intensity is similar after out-patient and in-patient ACL repair. Concern about pain should not be a barrier to performing ACL repair on an out-patient basis. Our data on the time-course of the pain and factors associated with greater pain intensity should prove useful for improving patient management after ACL repair. LEVEL OF EVIDENCE Level III, case-control study.
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Lefevre N, Klouche S, de Pamphilis O, Herman S, Gerometta A, Bohu Y. Peri-articular local infiltration analgesia versus femoral nerve block for postoperative pain control following anterior cruciate ligament reconstruction: Prospective, comparative, non-inferiority study. Orthop Traumatol Surg Res 2016; 102:873-877. [PMID: 27720193 DOI: 10.1016/j.otsr.2016.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/20/2016] [Accepted: 07/05/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Femoral nerve block (FNB) is considered as a major advance in anterior cruciate ligament (ACL) reconstruction as it reduces the need for parenteral opioids. However, the incidence of transient or even permanent neurological deficits due to the FNB is estimated at 1.94% after knee surgery. The primary objective of this study was to compare local infiltration analgesia (LIA) to FNB during ACL reconstruction procedures. The study hypothesis was that LIA was not less effective than FNB on early postoperative pain. PATIENTS AND METHODS A retrospective analysis of data collected prospectively in the FAST cohort included a series of continuous patients who underwent primary repair for isolated ACL with a hamstring graft in 2013-2014. Changes in our anesthesia practices over time allowed us to form three successive groups: Group 1 - FNB, Group 2 - FNB+LIA, Group 3 - LIA only. Ultrasound-guided FNB was done pre-operatively. The LIA was done at the end of the procedure by the surgeon with systematic infiltration of all skin incisions and the hamstring donor site; no intra-articular injections were performed. The primary endpoint was the average early postoperative pain (Days 0-3) described by the patient on a visual analogue scale (0-10). Sample size calculation pointed to 36 subjects being needed per group for a non-inferiority study. RESULTS The study involved 126 patients: G1=42, G2=38, G3=46. The patients were comparable at enrolment. The average early postoperative pain levels were 3.1±2.4, 2.8±2.0 and 2.5±2.2, respectively (P=0.66). A trend toward higher intake of tramadol was noted in the LIA group on D0 to D3, with a significant trend test on Day 1 (P=0.03) and Day 2 (P=0.02). CONCLUSION After reconstruction of isolated ACL tears with a hamstring graft, FNB is not more effective than LIA on patients' early postoperative pain. Patients who received a FNB consumed significantly less opioid-like analgesics. LEVEL OF EVIDENCE III - Prospective, comparative, non-randomized study.
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Affiliation(s)
- N Lefevre
- Clinique du Sport, 75005 Paris, France; Institut de l'Appareil Locomoteur Nollet, 75017 Paris, France.
| | - S Klouche
- Clinique du Sport, 75005 Paris, France; Institut de l'Appareil Locomoteur Nollet, 75017 Paris, France
| | | | - S Herman
- Clinique du Sport, 75005 Paris, France; Institut de l'Appareil Locomoteur Nollet, 75017 Paris, France
| | - A Gerometta
- Clinique du Sport, 75005 Paris, France; Institut de l'Appareil Locomoteur Nollet, 75017 Paris, France
| | - Y Bohu
- Clinique du Sport, 75005 Paris, France; Institut de l'Appareil Locomoteur Nollet, 75017 Paris, France
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