Vascular and Neurological Injury in Children With Posterior Traumatic Knee Dislocation

Posterior knee dislocations (PKD) in children are uncommon but may be associated with vascular injury. The purpose of this study is to characterize the frequency of vascular injury in PKD as well as define patient characteristic, procedures, types of treating hospitals, and clinical outcomes. This study utilized the National Trauma Data Set (NTDS) from the American College of Surgeons on years 2015 and 2016. All demographic and clinical data on pediatric patients (≤18 years) with the ICD codes for PKD were obtained. 44 PKD were identified. The median age was 17 years [IQR 15,18], 70% male; 49% white. The mean body mass index was 29.6 [IQR 23-38]. We found that vascular injury was present in 16 patients (36%); 14 (30%) underwent repair (eight with saphenous vein graft) and fasciotomies in eight patients. Nerve injury was present in five patients (11%). Lower extremity amputation was performed in three patients (7%).

Repair of popliteomeniscal fascicles tear using a posterior transseptal portal fixes hypermobile lateral meniscus

Purpose This study investigates the effects of the all-inside repair of posterosuperior popliteomeniscal fascicle (PMF) on lateral meniscus stabilization using a posterior arthroscopic approach. Methods Between 2015 and 2018, 17 patients with hypermobile lateral meniscus (HLM) underwent posterior knee arthroscopy for PMF repair. The all-inside repair was performed through posteromedial transseptal and posterolateral portals using a suture hook technique. Patients were clinically assessed based on IKDC and Lysholm scores. Results Both IKDC and Lysholm scores improved significantly after an average follow-up of 3.5 years (P < 0.001). No patients underwent reoperation, and no complications associated with posterior knee arthroscopy were reported. Conclusion The all-inside suture hook technique using posterolateral and posteromedial transseptal portals fixes HLM with excellent IKDC and Lysholm scores. Level of evidence Level IV.

Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis

The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: –1.18; 95% confidence interval [CI]: –2.05 to –0.30) and during activity (SMD: –0.26; 95% CI: –0.49 to –0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: –0.295; 95% CI: –0.543 to –0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.

Multimodal Analgesia Plus Intraoperative Hamstring Sheath Injection for Hamstring Autograft Anterior Cruciate Ligament Reconstruction Reduces Postoperative Posterior Knee Pain But Does Not Reduce Postoperative Narcotic Requirements: A Double-Blind Randomized Control Trial (171)

Objectives: This study’s objective was to determine whether multimodal analgesia plus an injection of the hamstring sheath immediately following the harvest of the semitendinosus and gracilis tendons during hamstring autograft anterior cruciate ligament reconstruction (ACLR) reduces postoperative pain. We hypothesized that multimodal analgesia plus a hamstring sheath injection of the harvest site for autograft hamstring ACLR reduces postoperative pain. Methods: The Institutional Review Board approved this study registered with ClinicalTrials.gov and identified by NCT01868425. This study was a single-center, surgeon stratified double-blind, placebo-controlled, randomized study from April 2013 to December 2017. Patients were randomly assigned to one of two groups, in a 1:1 ratio per surgeon, to receive either standard of care analgesia plus intra-operative hamstring sheath saline injection (Placebo group) or standard of care analgesia plus multimodal analgesia plus intraoperative hamstring sheath anesthetic injection (MA group) for patients undergoing ACLR with hamstring autograft. Eligible participants were adults aged 18 years to 55 years old consented for ACLR using hamstring tendon autograft. Contraindication to a femoral nerve block, allergy to protocol medications, nervous system disease, renal or hepatic impairment, history of opioid dependence or current narcotic use, significant psychiatric disease, pregnancy or lactating, a seizure disorder, history of postoperative nausea and vomiting, latex allergy, and clinically significant cardiac or pulmonary disease excluded patients for participation in this study. The primary endpoint was total postoperative opioid administration. Secondary endpoints included the patient’s subjective pain score for the posterior, anterior, and lateral side of the knee, postoperative nausea, sedation, and pruritus scores. Based on our preliminary data, we estimated the mean opioid for standard care will be 6.6 morphine equivalents with a standard deviation of 6.2 morphine equivalents. Testing the ability of multimodal analgesia to reduce opioid usage by at least 50%, a minimal sample size of 45 subjects per group was needed to achieve 80% power based on a one-tailed t-test and a significance level < 0.05. Student’s t-test compared outcomes between groups. Additionally, a linear regression model for was also used for the primary outcome with total opioid administration as the dependent variable in order to control for body mass index (BMI) and sex, providing an adjusted estimate of the difference between groups. Results: A total of 112 patients (Figure 1) met inclusion criteria and were randomized into the placebo group (n = 57) and MA group (n = 55). Demographic data demonstrated no significant differences between groups (Table 1). The primary analysis was postoperative opioid administration and included all patients randomly assigned to either group for opioid administration in the postoperative anesthetic care unit (PACU), however opioid administration in 24 hours after discharge was not recorded for five patients in the MA group, leaving 50 patients remaining for the per-protocol analyses. Secondary outcome data was not recorded for one patient in the placebo group leaving 56 patients remaining for the per-protocol analyses. The mean postoperative opioid needs (Table 2) for patients in the MA group (18.7 ± 13.14) was less than those in the placebo group (22.6 ± 11.15), although this was not statistically significant (p-value = 0.140). Secondary outcomes (Figure 2A) demonstrated a significant reduction in posterior knee pain postoperatively in the MA group (2.84 ± 2.25) compared to Placebo (3.56 ± 1.97; p-value = 0.0362). There were no significant differences in postoperative pain in the front or sides of the knee. Similarly, there were no significant differences in pruritis (MA: 0.26 ± 0.99 vs. Placebo: 0.696 ± 1.73; p-value = 0.2163), sedation (MA: 5.02 ± 2.29 vs. Placebo: 4.61 ± 2.16; p-value = 0.656), and nausea (MA: 1.16 ± 2.28 vs Placebo: 0.714 ± 1.72; p-value = 0.243) scores (Figure 2B). Conclusions: Multimodal analgesia plus hamstring sheath injection reduces postoperative patient reported posterior knee pain compared to placebo for patients undergoing ACLR using hamstring tendon autograft. However, multimodal analgesia plus a hamstring sheath injection does not reduce postoperative opioid requirements.

Mucoïde degeneratie van de voorste kruisband als oorzaak van diepe kniepijn

Mucoid degeneration of the anterior cruciate ligament: a little-known cause of deep knee pain Mucoid degeneration of the anterior cruciate ligament (ACL) is a little-known cause of deep atraumatic knee pain that is relatively frequent. Recent studies have reported a prevalence of 1,8-9,2% on MRI of the knee. Mucoid lesions consist of interstitial deposits of glycosaminoglycan between the collagen bundles. This causes hypertrophy of the ACL, which leads to mechanical impingement at the femoral notch, typically resulting in deep or posterior knee pain in terminal flexion and/or extension. Unlike the often-occurring traumatic ACL ruptures, there are no instability complaints. The gold standard for diagnosing mucoid degeneration of the ACL is MRI. This shows an abnormally thickened and ill-defined ACL with an increased intraligamentary signal on all sequences, but the orientation and continuity are usually maintained. Arthroscopically, the mucoid degeneration can be recognized by a hypertrophic ACL with yellowish to brown substances between the fibers. In addition, an absence of the synovial outline of the ACL is seen regularly. An arthroscopic partial or total ACL resection is the treatment of choice for symptomatic mucoid degeneration of the ACL and results in good post-operative outcomes without development of instability.