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Regional Anesthesia and Pain Medicine Jun 2024Hip arthroscopy causes severe pain during the first few hours in the postoperative care unit. This is probably due to the intraoperative stretching of the hip joint...
BACKGROUND
Hip arthroscopy causes severe pain during the first few hours in the postoperative care unit. This is probably due to the intraoperative stretching of the hip joint capsule. Pain relief requires high doses of opioids which may prolong recovery and may cause opioid-related adverse events.The majority of hip joint capsule nociceptors are located anteriorly. The obturator nerve innervates the anteromedial part of the hip joint capsule. We hypothesized that a subpectineal obturator nerve block using 15 ml bupivacaine 5 mg/mL with added epinephrine 5 μg/mL would reduce the opioid consumption after hip arthroscopy.
METHODS
40 ambulatory hip arthroscopy patients were enrolled in this randomized, triple-blind controlled trial. All patients were allocated to a preoperative active or placebo subpectineal obturator nerve block. The primary outcome was opioid consumption for the first 3 hours in the postanesthesia care unit. Secondary outcomes were pain, nausea, and hip adductor strength.
RESULTS
34 patients were analyzed for the primary outcome. The mean intravenous morphine equivalent consumption in the subpectineal obturator nerve block group was 11.9 mg vs 19.7 mg in the placebo group (p<0.001). The hip adductor strength was significantly reduced in the active group. No other intergroup differences were observed regarding the secondary outcomes.
CONCLUSION
We found a significant reduction in the opioid consumption for patients receiving an active subpectineal obturator nerve block. The postoperative intravenous morphine equivalent reduction the first painful 3 hours was reduced by 40% for patients receiving a subpectineal obturator nerve block in this randomized, triple-blind trial.
TRIAL REGISTRATION NUMBER
EudraCT database 2021-006575-42.
PubMed: 38925710
DOI: 10.1136/rapm-2024-105638 -
Arthroscopy : the Journal of... Jun 2024To provide a proof-of-concept analysis of the appropriateness and performance of ChatGPT-4 to triage, synthesize differential diagnoses, and generate treatment plans...
PURPOSE
To provide a proof-of-concept analysis of the appropriateness and performance of ChatGPT-4 to triage, synthesize differential diagnoses, and generate treatment plans concerning common presentations of knee pain.
METHODS
Twenty knee complaints warranting triage and expanded scenarios were input into ChatGPT-4, with memory cleared prior to each new input to mitigate bias. For the 10 triage complaints, ChatGPT-4 was asked to generate a differential diagnosis which was graded for accuracy and suitability in comparison to a differential created by two orthopaedic sports medicine physicians. For the 10 clinical scenarios, ChatGPT-4 was prompted to provide treatment guidance for the patient, which was again graded. To test the higher-order capabilities of ChatGPT-4, further inquiry into these specific management recommendations was performed and graded.
RESULTS
All ChatGPT-4 diagnoses were deemed appropriate within the spectrum of potential pathologies on a differential. The top diagnosis on the differential was identical between surgeons and ChatGPT-4 for 70% of scenarios, and the top diagnosis provided by the surgeon appeared as either the first or second diagnosis in 90% of scenarios. Overall, 16/30 (53.3%) of diagnoses in the differential were identical. When provided with 10 expanded vignettes with a single diagnosis, the accuracy of ChatGPT-4 increased to 100%, with the suitability of management graded as appropriate in 90% of cases. Specific information pertaining to conservative management, surgical approaches, and related treatments was appropriate and accurate in 100% of cases.
CONCLUSION
ChatGPT-4 provided clinically reasonable diagnoses to triage patient complaints of knee pain due to various underlying conditions that was generally consistent with differentials provided by sports medicine physicians. Diagnostic performance was enhanced when providing additional information, allowing ChatGPT-4 to reach high predictive accuracy for recommendations concerning management and treatment options. However, ChatGPT-4 may demonstrate clinically important error rates for diagnosis depending on prompting strategy and information provided; therefore, further are necessary to prior to implementation into clinical workflows.
PubMed: 38925234
DOI: 10.1016/j.arthro.2024.06.021 -
Arthroscopy : the Journal of... Jun 2024To investigate the effectiveness of bursal acromial resurfacing (acromiograft) on acromiohumeral distance, subacromial contact area, and pressure in a cadaveric model of...
PURPOSE
To investigate the effectiveness of bursal acromial resurfacing (acromiograft) on acromiohumeral distance, subacromial contact area, and pressure in a cadaveric model of massive rotator cuff tear.
METHODS
Eight fresh-frozen cadaveric shoulders were tested using a customized shoulder testing system. Humeral head translation, subacromial contact pressure, and the subacromial contact area were evaluated across four conditions: (1) intact shoulder; (2) simulated massive rotator cuff tear; (3) 3-mm acromiograft condition; (4) 6-mm acromiograft condition. The acromiografts were simulated using Teflon and a reported technique. The values were measured at 0°, 20°, and 40° abduction and 0°, 30°, 60°, and 90° external rotation (ER) for each abduction status.
RESULTS
Compared with a massive cuff tear, the 6-mm acromiograft significantly reduced the superior translation of the humeral head at all abduction/ER angles (P<0.05). The 3-mm acromiograft also decreased superior translation of the humeral head compared to massive cuff tear, but not all differences were significant. The 3- and 6-mm acromiografts significantly decreased the subacromial contact pressure and increased the subacromial contact area in almost all positions (P<0.05). The 3-mm acromiograft maintained biomechanical properties similar to the intact condition, whereas the 6-mm acromiograft increased the contact area.
CONCLUSIONS
This biomechanical study demonstrated that both 3- and 6- mm acromiografts using Teflon in a cadaveric model of a massive cuff tear resulted in recentering of the superiorly migrated humeral head, increased the subacromial contact area, and decreased the subacromial contact pressure. The 3- mm graft was sufficient for achieving the intended therapeutic effects.
CLINICAL RELEVANCE
The acromiograft can normalize altered biomechanics and may aid the treatment of massive cuff tears. As grafting the acromion's undersurface is new with limited clinical outcomes, further observation is crucial. Using Teflon instead of ADM allograft for bursal acromial resurfacing could yield different results, requiring careful interpretation.
PubMed: 38925233
DOI: 10.1016/j.arthro.2024.06.019 -
Arthroscopy : the Journal of... Jun 2024The purpose of this study was to evaluate the cost-utility of a Balloon Spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness...
PURPOSE
The purpose of this study was to evaluate the cost-utility of a Balloon Spacer implant relative to partial repair (PR) for the surgical treatment of full-thickness massive rotator cuff tears (MRCT).
METHODS
A decision-analytic model comparing Balloon Spacer versus PR was developed using data from a prospective, randomized, single-blinded, multi-center controlled trial of 184 randomized patients. Our model was constructed based on the various event pathways a patient could have after the procedure. The probability that each patient progressed to a given outcome and the quality-adjusted life years (QALY) associated with each outcome were derived from the clinical trial data. Incremental cost utility ratio (ICUR) and incremental net monetary benefit (INMB) were calculated based on a probabilistic sensitivity analysis using Monte Carlo simulations of 1,000 hypothetical patients progressing through the decision-analytic model. One-way sensitivity and threshold analyses were performed by varying cost, event probability, and QALY estimates.
RESULTS
Balloon Spacer had an ICUR of $106,851 (95% CI, $96,317 to $119,143) relative to PR for surgical treatment of MRCT. Across all patients, Balloon Spacer was associated with greater 2-year QALY gain compared to PR (0.20 ± 0.02 for Balloon Spacer versus 0.18 ± 0.02 for PR), but with substantially higher total 2-year cost ($9,701 ± $939 for Balloon Spacer versus $6,315 ± $627 for PR). PR was associated with a positive INMB of $1,802 (95% CI, $1,653 to $1,951) over Balloon Spacer at the $50,000/QALY willingness-to-pay (WTP) threshold.
CONCLUSIONS
Compared to PR, Balloon Spacer is an "intermediate value" innovation for treatment of MRCT over a 2-year postoperative period with an ICUR value that falls within the $50,000 to $150,000 WTP threshold.
PubMed: 38925232
DOI: 10.1016/j.arthro.2024.06.023 -
Arthroscopy : the Journal of... Jun 2024Surgeons have dealt with the negative effects of misinformation from "Dr. Google" since patients starting using search engines to seek out medical information. With the...
Surgeons have dealt with the negative effects of misinformation from "Dr. Google" since patients starting using search engines to seek out medical information. With the advent of natural language processing software such as ChatGPT, patients may have a seemingly real conversation with AI software. However, ChatGPT provides misinformation in response to medical questions, and responds at the reading level of a college freshman, whereas US National Institute of Health recommends medical information be written at a 6th grade level. The flaw of ChatGPT is that it recycles information from the internet. It is "artificially intelligent" because of its ability to mimic natural language - not because of its ability to understand and synthesize content. It fails to understand nuance or critically analyze new inputs. Ultimately, these skills require human intelligence, while ChatGPT provides responses that are exactly what you might expect - artificial.
PubMed: 38925231
DOI: 10.1016/j.arthro.2024.06.027 -
Clinical Orthopaedics and Related... Jan 2024
PubMed: 38924460
DOI: 10.1097/CORR.0000000000003139 -
JAMA Network Open Jun 2024Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing,...
IMPORTANCE
Opioid medications are commonly prescribed for the management of acute postoperative pain. In light of increasing awareness of the potential risks of opioid prescribing, data are needed to define the procedures and populations for which most opioid prescribing occurs.
OBJECTIVE
To identify the surgical procedures accounting for the highest proportion of opioids dispensed to adults after surgery in the United States.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional analysis of the 2020-2021 Merative MarketScan Commercial and Multi-State Databases, which capture medical and pharmacy claims for 23 million and 14 million annual privately insured patients and Medicaid beneficiaries, respectively, included surgical procedures for individuals aged 18 to 64 years with a discharge date between December 1, 2020, and November 30, 2021. Procedures were identified using a novel crosswalk between 3664 Current Procedural Terminology codes and 1082 procedure types. Data analysis was conducted from November to December 2023.
MAIN OUTCOMES AND MEASURES
The total amount of opioids dispensed within 3 days of discharge from surgery across all procedures in the sample, as measured in morphine milligram equivalents (MMEs), was calculated. The primary outcome was the proportion of total MMEs attributable to each procedure type, calculated separately among procedures for individuals aged 18 to 44 years and those aged 45 to 64 years.
RESULTS
Among 1 040 934 surgical procedures performed (mean [SD] age of patients, 45.5 [13.3] years; 663 609 [63.7%] female patients), 457 016 (43.9%) occurred among individuals aged 18 to 44 years and 583 918 (56.1%) among individuals aged 45 to 64 years. Opioid prescriptions were dispensed for 503 058 procedures (48.3%). Among individuals aged 18 to 44 years, cesarean delivery accounted for the highest proportion of total MMEs dispensed after surgery (19.4% [11 418 658 of 58 825 364 MMEs]). Among individuals aged 45 to 64 years, 4 of the top 5 procedures were common orthopedic procedures (eg, arthroplasty of knee, 9.7% of total MMEs [5 885 305 of 60 591 564 MMEs]; arthroscopy of knee, 6.5% [3 912 616 MMEs]).
CONCLUSIONS AND RELEVANCE
In this cross-sectional study of the distribution of postoperative opioid prescribing in the United States, a small number of common procedures accounted for a large proportion of MMEs dispensed after surgery. These findings suggest that the optimal design and targeting of surgical opioid stewardship initiatives in adults undergoing surgery should focus on the procedures that account for the most opioid dispensed following surgery over the life span, such as childbirth and orthopedic procedures. Going forward, systems that provide periodic surveillance of opioid prescribing and associated harms can direct quality improvement initiatives to reduce opioid-related morbidity and mortality.
Topics: Humans; Analgesics, Opioid; Adult; Female; Middle Aged; Male; Cross-Sectional Studies; Pain, Postoperative; Practice Patterns, Physicians'; Patient Discharge; United States; Adolescent; Young Adult; Drug Prescriptions; Surgical Procedures, Operative
PubMed: 38922619
DOI: 10.1001/jamanetworkopen.2024.17651 -
Arthroscopy : the Journal of... May 2024To determine the effect of bone marrow stimulation (BMS) on retear rates, functional outcomes, and complication rates in patients who underwent arthroscopic rotator cuff... (Meta-Analysis)
Meta-Analysis
Bone Marrow Stimulation Does Not Lead to Lower Retear Rates, Better Functional Outcomes, or Higher Complication Rates at Short-Term Follow-Up for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials.
PURPOSE
To determine the effect of bone marrow stimulation (BMS) on retear rates, functional outcomes, and complication rates in patients who underwent arthroscopic rotator cuff repair (RCR) through a meta-analysis of randomized controlled trials.
METHODS
PubMed, EMBASE, Web of Science, and The Cochrane Library were searched on March 25, 2023. Two evaluators independently screened the literature, extracted data, and assessed the methodologic quality of the enrolled studies. Meta-analysis was conducted using RevMan software, version 5.4.
RESULTS
A total of 7 randomized controlled trials with 638 patients were included. The evaluation of rotator cuff tendon integrity was conducted using distinct imaging modalities. Specifically, 259 patients underwent magnetic resonance imaging whereas 208 patients underwent ultrasound. Additionally, a subset of 95 patients underwent either of these modalities; however, the precise distribution between these 2 modalities was not explicitly delineated. Compared with RCR alone, RCR combined with BMS provided similar retear rates (P = .51, I = 46%), Constant-Murley scores (P = .14, I = 0%), American Shoulder and Elbow Surgeons (standardized shoulder assessment form) scores (P = .56, I = 0%), Western Ontario Rotator Cuff Index scores (P = .20, I = 0%), visual analog scale scores (P = .19, I = 0%), forward flexion (P = .18, I = 0%), external rotation (P = .62, I = 0%), severe complication rates (P = .56, I = 0%), and mild complication rates (P = .10, I = 0%).
CONCLUSIONS
Compared with the outcomes observed after isolated arthroscopic RCR, arthroscopic RCR with BMS showed comparable results in terms of retear rate, functional outcomes, and incidence of complications.
LEVEL OF EVIDENCE
Level II, meta-analysis of Level I and II studies.
Topics: Humans; Arthroscopy; Randomized Controlled Trials as Topic; Rotator Cuff Injuries; Treatment Outcome; Postoperative Complications; Bone Marrow; Rotator Cuff; Follow-Up Studies
PubMed: 38922600
DOI: 10.1016/j.arthro.2023.10.025 -
Pediatrics Jul 2024Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid...
BACKGROUND AND OBJECTIVES
Surgery is one of the most common indications for opioid prescribing to pediatric patients. We identified which procedures account for the most pediatric surgical opioid prescribing.
METHODS
We conducted a cross-sectional analysis of commercial and Medicaid claims in the Merative MarketScan Commercial and Multi-State Medicaid Databases. Analyses included surgical procedures for patients aged 0 to 21 years from December 1, 2020, to November 30, 2021. Procedures were identified using a novel crosswalk between 3664 procedure codes and 1082 procedure types. For each procedure type in the crosswalk, we calculated the total amount of opioids in prescriptions dispensed within 3 days of discharge from surgery, as measured in morphine milligram equivalents (MMEs). We then calculated the share of all MMEs accounted for by each procedure type. We conducted analyses separately among patients aged 0 to 11 and 12 to 21 years.
RESULTS
Among 107 597 procedures for patients aged 0 to 11 years, the top 3 procedures accounted for 59.1% of MMEs in opioid prescriptions dispensed after surgery: Tonsillectomy and/or adenoidectomy (50.3%), open treatment of upper extremity fracture (5.3%), and removal of deep implants (3.5%). Among 111 406 procedures for patients aged 12 to 21 years, the top 3 procedures accounted for 33.1% of MMEs: Tonsillectomy and/or adenoidectomy (12.7%), knee arthroscopy (12.6%), and cesarean delivery (7.8%).
CONCLUSIONS
Pediatric surgical opioid prescribing is concentrated among a small number of procedures. Targeting these procedures in opioid stewardship initiatives could help minimize the risks of opioid prescribing while maintaining effective postoperative pain control.
Topics: Humans; Child; Adolescent; Child, Preschool; Analgesics, Opioid; Infant; Cross-Sectional Studies; Pain, Postoperative; Practice Patterns, Physicians'; Young Adult; Female; Male; United States; Infant, Newborn; Drug Prescriptions; Surgical Procedures, Operative; Medicaid
PubMed: 38919985
DOI: 10.1542/peds.2024-065814 -
The Iowa Orthopaedic Journal 2024Posterior cruciate ligament (PCL) tears in young children are rare and optimal treatment is poorly described. Diagnosis may prove challenging as young children may not... (Review)
Review
BACKGROUND
Posterior cruciate ligament (PCL) tears in young children are rare and optimal treatment is poorly described. Diagnosis may prove challenging as young children may not be able to verbalize a complete history of injury, may be difficult to examine, and plane film radiographs often appear within normal limits. Surgical treatment carries a risk of physeal arrest, but non-operative treatment may lead to recurrent instability and pain.
METHODS
We present a case report of a fouryear- old child with a PCL avulsion off the femoral insertion who received an open reduction and internal fixation (ORIF) with combined arthroscopic synovial debridement. We performed a literature review which compared the mechanism, location, concomitant injuries, work up and management of PCL injuries in children under the age of ten compared to adolescents and adults.
RESULTS
Nineteen months following surgery, physical examination revealed full knee range of motion and return to baseline function. Imaging studies confirmed there was no evidence of physeal arrest.
CONCLUSION
ORIF with arthroscopy can be an effective method to treat PCL avulsions in children under the age of 10 years. This is similar to other case reports which reported positive outcomes with ORIF in this population. Large studies are needed to best understand optimal treatment modalities for PCL injuries in very young children. .
Topics: Humans; Posterior Cruciate Ligament; Arthroscopy; Child, Preschool; Male; Debridement; Knee Injuries; Range of Motion, Articular; Treatment Outcome; Fracture Fixation, Internal; Female
PubMed: 38919372
DOI: No ID Found