Elbow Surgery Research Articles

What's New in Orthopaedic Rehabilitation.

Injuries and disorders of the musculoskeletal system cause pain and loss of function, thereby leading to disability. The goal of rehabilitation medicine is to restore function in individuals with disability. This article presents evidence from studies published from March 2015 to February 2016 in the area of orthopaedic rehabilitation. Original articles from the American Journal of Physical Medicine & Rehabilitation, The American Journal of Sports Medicine, Archives of Physical Medicine and Rehabilitation, The Clinical Journal of Pain, JAMA, The Journal of Bone & Joint Surgery, The Journal of Pain, Journal of Shoulder and Elbow Surgery, The New England Journal of Medicine, Physical Therapy, and PM&R were considered. We screened the manuscript titles and abstracts of these select journals and included articles that were considered to be of high impact and value to readers. This Update is divided into sections based on subspecialty areas in physical medicine and orthopaedic rehabilitation. ### Osteoarthritis Intra-articular administration of hyaluronic acid is a pharmacological approach to the management of knee osteoarthritis. Several formulations of hyaluronic acid are commercially available. Altman et al. performed a meta-analysis of trials assessing the efficacy of hyaluronic acid formulations according to molecular weight1. Hyaluronic acid products with a molecular weight of ≥3,000 kDa had a pooled effect size of −0.52 (95% confidence interval [CI], −0.56 to −0.48) when pain reduction was the outcome. These were more efficacious than products that were 1,500 kDa and those that were ≤1,500 kDa in molecular weight. Whole-body vibration mediates the activation of alpha (α) motor neurons, which cause muscle contractions, thereby leading to increased muscle strength2. A recent meta-analysis of 5 studies showed preliminary data for improved pain and function with whole-body vibration training among patients with knee osteoarthritis compared with controls2. ### Total Knee Arthroplasty With increasing emphasis on cost-containment and …

The 2015 AOA North American Traveling Fellowship.

The North American Traveling Fellowship (NATF) is one of the flagship tours of the American Orthopaedic Association (AOA). NATF is geared toward advancing the careers of young orthopaedic surgeons through the promotion of clinical, scientific, and social exchange. The 2015 tour had a major emphasis on the development of leadership in the field of orthopaedics through close interactions and meetings with departmental chairs and administrators, as well as with hospital and medical school leaders. The 2015 NATF tour was in the Midwest corridor of Canada and the United States. The 5 fellows included specialists in spine, trauma, sports medicine, and shoulder and elbow surgery. Lifelong friendships and collaborations were formed during the tour. We visited 14 centers, and each site/host made great efforts to make us feel welcome and also organized excellent academic and social programs. By the conclusion of the tour, it was clear to all of us that this was a once in a lifetime experience, and we were honored to have the privilege of participating in such an amazing opportunity. The exposure to high-caliber leaders in our profession allowed us to appreciate different ways of balancing the intricacies of academic and clinical life, and these lessons will remain with us throughout our careers.

Level of clinical evidence presented at the open and closed American Shoulder and Elbow Surgeons annual meeting over 10 years (2005–2014)

BackgroundThe American Shoulder and Elbow Surgeons (ASES) annual scientific meetings are premier forums whereby orthopaedic surgeons are informed of the latest research advances in shoulder and elbow surgery. The purpose of the present study was to assess the Level of evidence (LOE) in the clinical papers presented at both the open and closed ASES annual scientific meetings from 2005 to 2014. Secondarily, the study evaluated whether there were any changes in the distribution of LOE over this period of time.MethodsTwo reviewers independently evaluated the abstracts of 532 paper presentations at either the open or closed ASES annual meetings. The independent reviewers first screened the abstracts for clinical evidence and excluded cadaveric, biomechanical, technique, and review studies. The included abstracts were then independently graded for methodological quality using LOE from Level I (highest quality) to IV (lowest quality) based on the classification system created by The American Academy of Orthopaedic Surgeons (AAOS).ResultsOverall, 421 presentations were included and graded for LOE. In general, 17% of the presentations were graded level I; 15% level II; 25% level III; and 43% assigned a LOE of IV. Chi-square analysis demonstrated a statistically significant improvement in the LOE of presentations at the open and closed ASES meetings combined (p = 0.028) between the years 2005 and 2014. In particular, the proportion of presentations graded as level IV significantly decreased over this period (p = <0.001).ConclusionsWhile most presentations at the ASES annual scientific meetings were of lower LOEs the percentage of level I evidence is greater than that reported at other Orthopaedic meetings. There has been a significant improvement in the LOE of clinical research at open and closed ASES meetings from 2005 to 2014. Specifically, the proportion of level IV studies have dramatically decreased over time.

What's New in Shoulder and Elbow Surgery.

Chamberlain, Aaron M. MD, MSc1; Namdari, Surena MD2; Keener, Jay D. MD1,a Author Information

PREFERED SURGICAL TECHNIQUE USED BY ORTHOPEDISTS IN ACUTE ACROMIOCLAVICULAR DISLOCATION.

ABSTRACTObjective:To determine whether training on shoulder and elbow surgery influences the orthopedist surgeons' preferred technique to address acute acromioclavicular joint dislocation (ACD). Methods:A survey was conducted with shoulder and elbow specialists and general orthopedists on their preferred technique to address acute ACD. Results:Thirty specialists and forty-five general orthopedists joined the study. Most specialists preferred the endobutton technique, while most general orthopedists preferred the modified Phemister procedure for coracoclavicular ligament repair using anchors. We found no difference between specialists and general orthopedists in the number of tunnels used to repair the coracoclavicular ligament; preferred method for wire insertion through the clavicular tunnels; buried versus unburied Kirschner wire insertion for acromioclavicular temporary fixation; and time for its removal; and regarding the suture thread used for deltotrapezoidal fascia closure. Conclusion:Training on shoulder and elbow surgery influences the surgeons' preferred technique to address acute ACD. Level of Evidence V, Expert Opinion.

Single, double or multiple-injection techniques for non-ultrasound guided axillary brachial plexus block in adults undergoing surgery of the lower arm.

Regional anaesthesia comprising axillary block of the brachial plexus is a common anaesthetic technique for distal upper limb surgery. This is an update of a review first published in 2006 and previously updated in 2011 and 2013. To compare the relative effects (benefits and harms) of three injection techniques (single, double and multiple) of axillary block of the brachial plexus for distal upper extremity surgery. We considered these effects primarily in terms of anaesthetic effectiveness; the complication rate (neurological and vascular); and pain and discomfort caused by performance of the block. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE (1946 to April Week 1 2016), Embase (1947 to April 18 2016) and reference lists of trials. We contacted trial authors. The date of the last search was April 2016 (updated from March 2013). We included randomized controlled trials that compared double with single-injection techniques, multiple with single-injection techniques, or multiple with double-injection techniques for axillary block in adults undergoing surgery of the distal upper limb. We excluded trials using ultrasound-guided techniques. Independent study selection, 'Risk of bias' assessment and data extraction were performed by at least two investigators. We undertook meta-analysis. We included one new trial involving 45 participants in this updated review. In total we included 22 trials involving a total of 2193 participants who received regional anaesthesia for hand, wrist, forearm or elbow surgery. 'Risk of bias' assessment indicated that trial design and conduct were generally adequate; the most common areas of weakness were in blinding and allocation concealment.Nine trials comparing double versus single injections showed a statistically significant decrease in primary anaesthesia failure (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.34 to 0.89, high-quality evidence). Subgroup analysis by method of nerve location showed that the effect size was greater when neurostimulation was used rather than the transarterial technique.Nine trials comparing multiple with single injections showed a statistically significant decrease in primary anaesthesia failure (RR 0.25, 95% CI 0.14 to 0.42, high-quality evidence). Pooled data from five trials also showed a significant decrease in incomplete motor block (RR 0.61, 95% CI 0.39 to 0.96, high-quality evidence) in the multiple-injection group.Twelve trials comparing multiple versus double injections showed a statistically significant decrease in primary anaesthesia failure (RR 0.27, 95% CI 0.19 to 0.39, high-quality evidence). Pooled data from six trials also showed a significant decrease in incomplete motor block (RR 0.55, 95% CI 0.36 to 0.85, high-quality evidence) in the multiple injection group.Tourniquet pain was significantly reduced with multiple injections compared with double injections (RR 0.53, 95% CI 0.33 to 0.84, high-quality evidence). Otherwise there were no statistically significant differences between groups in any of the three comparisons on secondary analgesia failure, complications and patient discomfort. Compared with multiple injections, the time for block performance was significantly shorter for single injection (MD 3.33 minutes, 95% CI 2.76 to 3.90) and double injections (MD 1.54 minutes, 95% CI 0.80 to 2.29); however there was no difference in time to readiness for surgery. This review provides evidence that multiple-injection techniques using nerve stimulation for axillary plexus block produce more effective anaesthesia than either double or single-injection techniques. However, there was insufficient evidence to draw any definitive conclusions regarding differences in other outcomes, including safety.

Are eponyms used correctly or not? A literature review with a focus on shoulder and elbow surgery.

Eponymous terms are used frequently in daily patient care and scientific literature. They remind us of our predecessors in surgery. It is debatable whether eponymous terms are reliable in case of information transfer. The aim of our study was to investigate whether the original meaning of eponymous terms in shoulder and elbow surgery has been preserved in its use in contemporary literature. To evaluate whether eponymous terms were used correctly, we analysed the use of frequently encountered eponymous terms from January to December 2014. By means of a PubMed search, articles with eponymous terms were identified and analysed for the way an eponymous term was used, and we compared it with the original description. The original description was traced back to the index publication. The use of the eponymous term was scored as similar, divergent or undefined. In the search for eponymous terms, we included those eponymous terms that were used more than 10 times in the English, German and Dutch literature of 2014. 6 eponymous terms were eligible for analysis: Bankart lesion, Bristow-Latarjet procedure, Essex-Lopresti injury of the forearm, Galeazzi fracture, Hill-Sachs lesion and Monteggia fracture. We analysed 96 articles with the listed eponymous terms, of which 27 (28%) were scored divergent, 32 (33%) undefined and 37 (39%) similar. Bristow-Latarjet scored lowest, with 0% descriptions similar to the original, meaning that all articles had an undefined or divergent eponym, and Essex-Lopresti scored highest with 82% similarity. Eponymous terms in shoulder and elbow trauma and surgery are used inadequately and inconsistently. The use of eponymous terms probably cannot be avoided, but since the majority of eponymous terms are not used properly and understanding of its meaning and content varies from surgeon to surgeon, we should be keen on explaining the meaning of eponymous terms when using them.

Routine radiographs at time of pin removal after closed reduction and percutaneous pinning for type 2 supracondylar humerus fractures do not change management: a retrospective cohort study.

PurposeRadiographs are usually taken on day of pin removal for children treated with closed reduction and percutaneous pinning (CRPP) of type 2 supracondylar humerus fractures. The purpose of this study was to determine whether radiographs taken at time of pin removal for patients recovering uneventfully alter management.MethodsAfter IRB approval, billing records identified 1213 patients aged 1–10 years who underwent elbow surgery between 2007 and 2013 at our institution for a supracondylar humerus fracture. Of these patients, 389 met inclusion criteria. Clinical charts were reviewed for demographics, operative details, and clinical follow-up, focusing on clinical symptoms present at pin removal. Radiographs taken at time of pin removal and subsequent visits were assessed for healing and fracture alignment.ResultsIn no case was pin removal delayed based on radiographs. One hundred and nineteen (31 %) patients had radiographs taken following pin removal; in no case was loss of reduction found among these patients. No cases of neurologic or vascular injury, re-fracture, or loss of reduction occurred. Infection occurred in 12 patients (3 %). Pins were kept in place for 23.8 ± 4.4 days. Eighty-six patients (22 %) had additional intervention after pin removal (cast application in all cases). Of 389 patients, 75 (19 %) had no documented reason for extended casting, four (1 %) were extended based on physician evaluation of radiographs, and seven (2 %) were extended for other reasons.ConclusionsElimination of radiographs at time of pin removal should be considered. If continuing to obtain radiographs at pin removal, we recommend removing pins before taking radiographs to reduce patient fear and anxiety from visualizing percutaneous pins.

Investigation of Biomechanical Characteristics of Intact Supraspinatus Tendons in Subacromial Impingement Syndrome: A Cross-sectional Study with Real-time Sonoelastography.

The aim of this work was to evaluate the real-time sonoelastography (RTSE) in the assessment of the supraspinatus tendon in patients with subacromial impingement syndrome (SIS). Twenty-five patients with unilateral shoulder pain that was diagnosed as SIS according to magnetic resonance imaging findings were included in the study. Healthy shoulders of the patients comprised the control group. Bilateral shoulder RTSE examinations were performed by a radiologist who was blinded to the involved side of the participants. The RTSE images were recorded and assessed by 2 radiologists individually 1 month later. American Shoulder and Elbow Surgery shoulder index, Quick Disabilities of Arm Shoulder and Hand Questionnaire, and Constant scores were applied to evaluate the disability and functional status. The correlation between strain ratio and functional scores were investigated. Of the 25 participants, 9 (36%) were men and 16 (64%) were women. The RTSE findings were pathologic in tendons of 23 patients (92%) with SIS. The strain ratio was significantly higher in the affected shoulders (P < 0.001). The interobserver agreement was good for image analysis. There was no significant correlation between strain ratio and functional scores. Structural changes in the supraspinatus tendon can be demonstrated with RTSE in patients with SIS.

Interosseous membrane reconstruction with a suture-button construct for treatment of chronic forearm instability

The purpose of this study was to report outcomes of interosseous membrane (IOM) reconstruction with a suture-button construct for treatment of chronic longitudinal forearm instability. We performed a retrospective review with prospective follow-up of patients who underwent ulnar shortening osteotomy and IOM reconstruction with the Mini TightRope device from 2011 through 2014. Bivariate statistical analysis was used for comparison of preoperative and postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, range of motion, grip strength, and ulnar variance. Complications and patient satisfaction were also recorded. Ten patients (mean age, 45.3 years) satisfied inclusion criteria: 8 treated for post-traumatic sequelae of Essex-Lopresti-type injuries, 1 for forearm instability secondary to previous elbow surgery, and 1 for instability secondary to trauma and multiple elbow surgeries. Surgeries were performed an average of 28.6 months from initial injury. At mean follow-up of 34.6 months after surgery, significant improvement was observed in elbow flexion-extension arc (+23° vs. preoperatively; P = .007), wrist flexion-extension arc (+22°; P = .016), QuickDASH score (-48; P = .000), and ulnar variance (-3.3 mm; P = .006). Three patients required additional surgery: 1 revision ulnar shortening osteotomy for persistent impingement, 1 revision ulnar osteotomy and Mini TightRope removal for lost forearm supination, and 1 fixation of a radial shaft fracture after a fall. IOM reconstruction using a suture-button construct is an effective treatment option for chronic forearm instability.

An Expedited Care Pathway With Ambulatory Brachial Plexus Analgesia Is a Cost-effective Alternative to Standard Inpatient Care After Complex Arthroscopic Elbow Surgery

(Abstracted from Anesthesiology, 123:1256–1266, 2015) The current standard practice for complex arthroscopic elbow surgery is inpatient admission for 72 hours with intensive physiotherapy via continuous passive motion, 24 hours a day for 3 days, and continuous brachial plexus analgesia for pain. The authors of the current study tested an expedited care pathway, with only 24 hours of hospital admission and ambulatory brachial plexus analgesia and continuous passive motion performed at home.

Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly.

The role of reverse total shoulder arthroplasty (RTSA) for three and four-part proximal humerus fractures is evolving. However, there does not appear to be a clear consensus amongst surgeons. The purpose of this study is to further define the standard of care, assessing surgeon preference and treatment considerations for management of such fractures. Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures. The survey also presented five representative cases to assess treatment preferences. Two hundred five surgeons responded to the survey with fellowship training in shoulder and elbow surgery (114), orthopaedic trauma (35) or sports medicine/other training (56). There was no difference between respondents with years in practice and confidence with performing RTSA, however, surgeons in the academic setting were more confident in performing the surgery. Surgeons preferred RTSA for management of four-part fractures in patients over age 65. However, they also trended to favour hemiarthroplasty with higher co-morbidities. Physicians with more than 11years of experience were more likely to choose hemiarthroplasty for older and high comorbidity patients. RTSA was not the preferred treatment method for younger, active patients. Patient age and fracture pattern had a greater influence on the surgeon's decision. There is a consensus in our study population that RTSA is the preferred treatment for four-part proximal humerus fractures for elderly patients with patient age and fracture pattern being the most important factors in making management decisions. Level III - Case controlled study.

Radial Head Fractures Treated with Modular Metallic Radial Head Replacement: Outcomes at a Mean Follow-up of Eight Years.

Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes at a minimum follow-up of five years after radial head arthroplasty with a modular metallic implant for the treatment of acute radial head fractures. The cases of fifty-five patients with unreconstructible radial head fractures treated acutely with a smooth-stemmed modular metallic radial head implant were retrospectively reviewed. A wide variety of injuries, which ranged from isolated radial head fractures to so-called terrible triad injuries, were included. All patients returned for an interview, physical examination, and radiographic evaluation at a mean of eight years (range, five to fourteen years) postoperatively. Elbow and forearm motion, elbow strength, and grip strength were measured. Radiographs were evaluated, and validated patient-rated outcome questionnaires were completed. A longitudinal subgroup analysis was performed for thirty-three patients who were previously evaluated at two years postoperatively. At a mean of 8.2 ± 2.9 years, the mean arc of flexion (and standard deviation) of the affected elbow was 11° ± 14° to 137° ± 15°. Elbow strength and motion were significantly diminished compared with the unaffected elbow (p < 0.05). The mean Mayo Elbow Performance Index (MEPI) was 91 ± 13 points. Twenty-five patients (45%) had stem lucencies; twenty-one (38%), ulnohumeral arthritis; and twenty (36%), heterotopic ossification, including one with radioulnar synostosis. Two patients underwent secondary elbow surgery, but no patient required implant removal or revision. In the subgroup evaluated longitudinally, there was a significant improvement in MEPI scores from the two-year to the eight-year follow-up (p = 0.012), with no loss of motion or strength (p > 0.05). The mid-term outcomes of radial head arthroplasty with a smooth-stemmed modular metallic prosthesis are comparable with previously reported short-term outcomes, with no evidence of functional deterioration. Radial head arthroplasty with a smooth-stemmed metallic modular implant is a good treatment option for patients with acute unreconstructible radial head fractures, and sustained clinical outcomes may be expected beyond five years of follow-up. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Shoulder and Elbow Injury Rates and Patterns in Korean Rookie Professional Baseball Pitchers

Background: To investigate how many rookie pitchers suffered from injuries while playing in the amateur league without guidelines for prevention of excessive pitching, we analyzed their amateur pitching patterns based on the pitch count, use of breaking balls, and pitches during winter camp. Methods: Forty-one rookie pitchers who graduated from high school or university in 2013 and joined professional baseball teams. Participants were interviewed by a trainer using our questionnaire. Injury inclusion criteria were 1) history of shoulder surgery, 2) history of elbow surgery, 3) shoulder pain requiring treatment, and 4) elbow pain requiring treatment. Results: Mean number of pitches per game and warm-up pitches for practice was 84.5 pitches (range, 15 to 130 pitches) and 16.4 pitches (range, 2 to 210 pitches), respectively. Mean number of pitches during the last year was 906.9 (range, 80 to 2,000). Mean number of maximal pitches was 127 pitches (range, 50 to 210 pitches). Fourteen pitchers had pitched over 150 pitches. Twenty-seven pitchers (65.9%) had pitched in spite of enduring pain. During winter training (mean 1.8 months), mean number of pitches per day was 162.5 pitches, and 20 pitchers (48.8%) had practiced pitching excessively despite the cold weather. Twenty-six rookies (63.4%) had shoulder pain or history of shoulder surgery, and 31 pitchers (75.6%) had elbow pain or history of elbow surgery. Only four participants (9.8%) did not have pain and history of surgery. Conclusions: For young baseball pitchers, guidelines for prevention of excessive pitching and for regulating the winter training program may be needed.

Intraoperative 3D imaging in the treatment of elbow fractures--a retrospective analysis of indications, intraoperative revision rates, and implications in 36 cases.

BackgroundThree-dimensional (3D) imaging with a mobile C-arm has proven to be a valuable intraoperative tool in trauma surgery. However, little data is available concerning its use in the treatment of elbow fractures. The aim of the current study was to determine the intraoperative findings and consequences of 3D imaging in the treatment of elbow fractures.MethodsBetween 2001 and 2015, prospectively collected data of 36 patients who underwent intraoperative 3D imaging during elbow surgery were recorded. The findings and consequences of the intraoperative 3D scans were analyzed in a retrospective chart review. For clinical evaluation the analysis included the patients’ medical history, the injury pattern of the affected elbow and concomitant injuries. Intraoperative and postoperative complications and revision surgeries were evaluated as well.ResultsIn 6 patients (16.7 %) analysis of the intraoperative 3D scan led to an immediate revision due to the detection of intra-articular screw placement (n = 3, 8.3 %) and remaining intra-articular step of >2 mm (n = 3, 8.3 %). In all of these patients, correct implant positioning and anatomical reduction could be achieved after immediate intraoperative revision, which was verified by a repeated intraoperative 3D scan. None of the 36 patients needed surgical revision based on postoperative radiological examinations due to secondary dislocation, wrong implant placement or remaining steps in the articular surface.ConclusionsIntraoperative 3D imaging offers additional information about fracture reduction and implant positioning in the treatment of elbow fractures compared to conventional intraoperative 2D imaging. It may therefore reduce the need for revision surgery. The value of intraoperative 3D imaging for clinical outcomes still needs to be assessed.

The Impact of Fatigue on Baseball Pitching Mechanics in Adolescent Male Pitchers

To determine if shoulder and elbow kinematics, pitching velocity and accuracy, and pain change during a simulated baseball game in adolescent pitchers. Adolescent male pitchers aged 13 to 16years were included. Pitchers were excluded if they had undergone previous shoulder or elbow surgery, currently had a known shoulder or elbow injury, or were unable to complete the simulated game for any reason. Shoulder range of motion was assessed before and after the game. Velocity and accuracy were measured for every pitch, and every 15th pitch was videotaped from 2 orthogonal views in high definition at 240Hz. Quantitative and qualitative mechanics were measured from these videos. Perceived fatigue and pain were assessed after each inning using a visual analog scale. Data were statistically analyzed using a repeated-measures analysis of variance. Twenty-eight elite adolescent pitchers were included. These pitchers, on average, were aged 14.6 ± 0.9years (mean ± standard deviation), had been pitching for 6.3 ± 1.7years, and threw 94 ± 58 pitches per week. Our experimental model functioned as expected in that pitchers became progressively more fatigued (0.3 ± 0.6 to 3.5 ± 2.1), had more pain (0.1 ± 0.4 to 1.6 ± 2.2), and pitched with a lower velocity (73 ± 5 mph to 71 ± 6 mph) as pitch number increased (P < .001, P= .001, and P < .001, respectively). Knee flexion at ball release progressively increased (49° ± 15° to 53° ± 15°) with pitch number (P= .008). Hip-to-shoulder separation significantly decreased as pitch number increased, from 90% ± 40% at pitch 15 to 40% ± 50% at pitch 90 (P < .001). Upper extremity kinematics remained unchanged (P > .271 in all cases, 91% power for elbow flexion at ball release). External rotation and total range of motion in the pitching shoulder significantly increased after pitching (P= .007 and P= .047, respectively). As pitchers progress through a simulated game, they throw lower-velocity pitches, become fatigued, and have more pain. Core and leg musculature becomes fatigued before upper extremity kinematics changes. On the basis of these results, there is the potential that core strengthening and leg strengthening may be valuable adjuncts to prevent upper extremity injury. Further studies specifically looking at this must be conducted.

Effects on ROM and Pain Relief of DC-type Micro Current Electric Therapy After Elbow Surgery

Effects on ROM and Pain Relief of DC-type Micro Current Electric Therapy After Elbow Surgery

An Analysis on the Effect of Patient-controlled Analgesia Performed by Orthopaedic Department or Postoperative Pain Control after Shoulder and Elbow Surgery

Background: We investigated the effectiveness of pain management and the adverse events of intravenous (IV) patient-controlled analgesia (PCA) after orthopedic surgery. Methods: From September 2014 and August 2015, we performed a retrospective analysis of 77 patients who underwent orthopedic surgery of the shoulder or the elbow in our hospital. The composition of the intravenous PCA administered to the patients was as follows: 250 mg of dexketoprofen trametamol, 70 mg of oxycodone, and 0.6 mg of ramosetron, which were made up to 79 ml of normal saline. We evaluated and statistically analyzed the difference in the visual analogue scale (VAS) scores for pain at immediate postoperation, at 24 hours of PCA, at 72 hours of PCA, and after discontinuation of PCA and in the incidence of adverse events. Results: We found that VAS score decreased for 3 postoperative days and that with discontinuation of IV PCA a meaningful change in VAS score was no longer seen. Of the 77 patients, 22 presented with adverse events (28.6%). We terminated IV PCA temporarily in the 21 patients who presented with adverse events; we terminated analgesia permanently in one patient (1.2%). Consequently, 76 of 77 patients carried out IV PCA till the designated period. Conclusions: Intravenous PCA after orthopedic surgery of the shoulder or the elbow may be accompanied with adverse events. Careful assessment of the patient and treatment of the adverse outcomes are key to a successful maintenance of PCA and to a successful management of postoperative pain.

Differences in Attentional Focus Associated With Recovery From Sports Injury: Does Injury Induce an Internal Focus?

Although it is commonly believed that focusing too much attention on the injured body area impairs recovery in sports, this has not been directly assessed. The present study investigated attentional focus following sports injury. Experienced baseball position players recovering from knee surgery (Expt 1) and baseball pitchers recovering from elbow surgery (Expt 2) performed simulated batting and pitching respectively. They also performed three different secondary tasks: leg angle judgments, arm angle judgments, and judgments about the ball leaving their bat/hand. Injured athletes were compared with expert and novice control groups. Performance on the secondary tasks indicated that the injured batters had an internal focus of attention localized on the area of the injury resulting in significantly poorer batting performance as compared with the expert controls. Injured pitchers had a diffuse, internal attentional focus similar to that of novices resulting in poorer pitching performance as compared with the expert controls.

Ambulatory Continuous Peripheral Nerve Blocks and the Perioperative Surgical Home.

Ambulatory Continuous Peripheral Nerve Blocks and the Perioperative Surgical Home Brian M. Ilfeld, M.D., M.S., Matthew J. Meunier, M.D., Alex Macario, M.D., M.B.A. A continuous peripheral nerve block (CPNB) consists of a percutaneously inserted peri- neural catheter and subsequent local anesthetic administration to provide site-specific analgesia. With a portable infusion pump, a perineural local anesthetic infu- sion may be provided for patients at home. 1 An article published in this issue of A nesthesiology by Eng et al. 2 suggests that, after major elbow surgery, transferring care from the hospital to the periopera- tive surgical home in the presence of an ambulatory CPNB decreases hospitalization costs without com- promising medical outcomes. Initially, ambulatory CPNB was used solely for postoperative outpatients—patients who were never intended to be hospital- ized overnight—to supplement oral analgesics and improve pain control. 3 Publication of studies of uncontrolled series of patients dis- charged the morning after hip and tricompartment knee arthroplasty suggested that ambulatory CPNB might also shorten hospitaliza- tions for procedures in which inpatient stays were related mainly to postoperative pain. Adding to the optimism, previously published evidence had demonstrated that 2 to 3 days of CPNB provided solely within the hospital could shorten long-term rehabilitation stays by improving joint range of motion up to 6 weeks after knee arthroplasty or arthrolysis. 4,5 Subsequent randomized, controlled trials found that ambu- latory CPNB decreases the time to discharge readiness after knee and hip arthroplasty. However, these subjects were not allowed to actually leave the hospital much earlier than the control group, leaving any benefits of earlier discharge as a the- oretical possibility. 3 The one randomized, placebo-controlled “One can imagine a well- functioning acute regional service that delivers state- of-the-art outpatient anal- gesia as a component for the promise of the peri­ operative surgical home to be fully realized.” trial demonstrating hastening of actual discharge using ambula- tory CPNB investigated the effects on range of motion after shoulder arthroplasty only through the day after surgery. 6 Although research over the last two decades has led to speculation that ambulatory CPNB might shorten hospitalization after major orthopedic surgery, actual evidence quantifying the benefits and risks remains elusive and wor- thy of continued investigation. One can imagine a well-functioning acute regional service that delivers state-of-the-art outpatient analgesia as a component for the promise of the perioperative surgical home to be fully realized. 7 New Study Providing such evidence makes an article published in this issue of A nesthesiology by Eng et al. 2 unique and noteworthy. Instead of studying the effects of ambula- tory perineural infusion on vari- ous endpoints—as has been done previously—the authors investi- gated the effects of early discharge by providing all subjects having major elbow surgery with a continuous infraclavicular nerve block for a total of 60 h and randomized them to a control group remaining hospitalized for 3 days, and an experimental group permitted early dis- charge the day after surgery. Subjects discharged home the day after surgery had similar elbow range of motion after 2 weeks and 3 months compared with those hospitalized for at least 3 days. Similarly, there were no statistically significant differences in pain scores, opi- oid consumption, patient satisfaction, and function-related questionnaires. In addition, the cost of care for those hospi- talized only one night were lower than for patients staying three nights. Although previous research has suggested the Image: Summit Medical, Salt Lake City, Utah. Corresponding article on page XXX. Accepted for publication September 1, 2015. From the Department of Anesthesiology, University of California San Diego, San Diego, California (B.M.I); Outcomes Research Consortium, Cleveland, Ohio (B.M.I); Department of Orthopedic Surgery, University of California San Diego, San Diego, California (M.J.M); and Departments of Anesthesiology, Perioperative and Pain Medicine and Health Research and Policy, Stanford University, Palo Alto, California (A.M.). Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2015; 123:00-00 Anesthesiology, V 123 • No 6 December 2015 Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Downloaded From: http://anesthesiology.pubs.asahq.org/pdfaccess.ashx?url=/data/Journals/JASA/0/ by BRIAN ILFELD on 10/22/2015