MID-AMERICA ORTHOPAEDIC ASSOCIATION 29 th Annual Meeting April 6-10, 2011 Hilton Tucson El Conquistador Resort Tucson, AZ NOTE: Disclosure information is listed at the end of this document. MAOA FIRST PLENARY SESSION April 7, 2011 1. Peripheral Nerve Blocks and Incidence of Postoperative Neurogenic Complaints and Pain Scores *Randy R. Clark, M.D. Iowa City, IA John P. Albright, M.D. Iowa City, IA Richard C. Johnston, M.D. Iowa City, IA Peripheral nerve blocks (PNBs) are a common adjuvant for anesthesia. In our experience PNBs cause a significant incidence of severe pain and neurologic complaints. We instituted a previously validated questionnaire completed by patients at their first postoperative visit. We asked patients to indicate if they received a PNB and to rate their pain on a standardized pain scale at several points in the postoperative period. Patients indicated if they experienced severe pain, had to return to the ER, and if they experienced lasting neurologic complaints. Comparative data was collected on patients who received a PNB and those who did not receive a PNB (control). 307 patients completed the survey, 244 patients with PNBs and 63 control patients. There was a 39.8% incidence of neurologic complaints in patients who received PNBs as compared to 9.5% incidence in patients who did not receive a PNB, P < 0.001. There was 27.9% (PNB) versus 14.3% (control) incidence of severe pain, P 0.027. Twenty-four patients that received PNBs versus five control patients visited the ER, P 0.65. Patients who received PNBs had significantly better pain control immediately after surgery (P 0.02) and trended towards improved pain control the same night (P 0.055), but there was no difference in pain control the morning after surgery, 24 hours after surgery, and at the one week postoperative period (P 0.99, 0.19, and 0.88). Patients who receive PNBs are at an increased risk for developing postoperative neurologic complaints as compared to control groups. Patients who receive PNBs have improved initial pain control, but the pain control profile shows no difference after less than 24 hours. Patients who receive PNBs experience more severe pain. This data demonstrates a significant incidence of unexpected neurologic complaints. Surgeons should counsel their patients about the potential risk of PNBs. 2. Prospective Randomized Evaluation of the Need for Blood Transfusion During Primary Total Hip Arthroplasty with Use of a Bipolar Sealer *Wael K. Barsoum, M.D. Cleveland, OH Alison K. Klika, M.S. Cleveland, OH Trevor G. Murray, M.D. Cleveland, OH Carlos A. Higuera, M.D. Cleveland, OH Ho H. Lee, M.D. Cleveland, OH Viktor E. Krebs, M.D. Cleveland, OH INTRODUCTION: The purpose of this study was to test for differences in transfusion requirements, clinical, functional, and health related quality of life patient outcomes in patients managed with total hip arthroplasty (THA) with and without the use of the bipolar sealer. Our research question addresses whether this device warrants routine use in the healthy, relatively uncomplicated population of THA patients. METHODS: This prospective, single-center, randomized, double-blinded study was designed to enroll 140 patients, randomized to either the treatment arm (radiofrequency using Aquamantys 6.0™) or control arm (standard ‘bovie’ electrocautery). Patients with low preoperative hemoglobin (i.e., under 11.5 g/dL) or bleeding abnormalities were excluded. The primary outcome measure was transfusion requirement, while secondary outcome measures were operative estimated blood loss, postoperative hemoglobin levels, perioperative narcotics usage, and postoperative function (Harris hip score and Short Form-12 quality of life scores). RESULTS: Seventy-one patients were assigned to the treatment arm and 69 were assigned to the control arm. Mean units transfused for all patients in the study arm and control arm were 0.38 and 0.44 units, respectively (p = 0.72). Transfusion requirements were similar between the two groups with the treatment arm having 15/71 patients transfused and the control arm with 14/69 transfused (p = 0.9). No significant differences were detected between groups in terms of secondary outcome measures. CONCLUSIONS: In this patient population, no significant reductions in the need for blood transfusions overall blood loss were observed. Given these findings, we have discontinued the use of this bipolar sealing device in uncomplicated primary THA patients. 3. Stress Examination of Supination External Rotation Ankle Fractures: Prospective Randomized Trial of Emergency Department Lateral Gravity Stress versus Manual Stress *Clifford B. Jones, M.D. Grand Rapids, MI Debra L. Sietsema, Ph.D., R.N. Grand Rapids, MI Enesi Mumoh, M.D. Grand Rapids, MI INTRODUCTION: Supination External Rotation (SER) ankle fractures are common injuries presenting with varying amounts of fracture displacement and mortise congruency. Manual stress (MS) has been the gold standard of determining deltoid ligament injury and associated ankle instability. The goal of this study was to determine the effectiveness and satisfaction of MS versus lateral gravity stress (LGS) in a prospective randomized trial. METHODS: With IRB approval, 73 consecutive isolated SER ankle fractures over a two-year period (2007-2009), at a Level-1 Trauma Center, were randomized to LGS versus MS. No patients were given sedation during the procedure. RESULTS: Of the 73 total SER ankle fractures, 38 (52.1%) and 35 (47.9%) were randomized to LGS and MS, respectively. Males and females comprised 50.7% (37) and 49.3% (36), respectively. The average age was 46 (range 18-87). No statistically significant differences were noted in relation to age, sex, or BMI. Average time from ED admission to stress was 175 minutes (range 26-666) with LGS and MS averaging 181 minutes and 171 minutes, respectively. Time did not vary based upon day of week. Pain averaged 5.5/10 and 5.3/10 for pre and post stress, respectively. Pain was significantly less for LGS as compared to MS after stress at 4.3/10 versus 6.4/10, respectively (p = 0.005). The amount of pain, length of time in ED, and overall satisfaction were 1.9/4, 1.8/4, and 1.5/4, respectively. Patients with more pain after stress were less satisfied with amount of pain during stress procedure (r = 0.537, p < 0.001). The ED experience and satisfaction was inversely related to length of time spent in ED (r = 0.684, p < 0.001). DISCUSSION: LGS is as effective as MS in determining deltoid ligament injury and instability of SER ankle fractures, but is less painful and can be performed without orthopedic resident assistance or time delays. Timely and effective deployment of the LGS could improve diagnosis of deltoid ligament injury, ED throughput, patient satisfaction, and lessen orthopedic resident services in busy Level-1 trauma centers. 4. Incidence of Symptomatic Venous Thromboembolism After Knee Arthroscopy Joseph A. Morgan, M.D. Columbia, MO Aaron J. Krych, M.D. Rochester, MN Bruce A. Levy, M.D. Rochester, MN Michael J. Stuart, M.D. Rochester, MN *Diane L. Dahm, M.D. Rochester, MN INTRODUCTION: Venous thromboembolic events (VTE) are a rare but potentially serious complication following knee arthroscopy. The purpose of this study was to determine the incidence of VTE after knee arthroscopy at a single institution, and to determine associated risk factors for VTE in these patients. METHODS: The records of all patients who underwent arthroscopy at a single institution between 1985 and 2005 were reviewed. Confirmed VTE events occurring within four weeks following the index arthroscopy procedure were noted. A 2:1 matched control group was generated to include patients for whom knee arthroscopy was performed by the same surgeon either on the same day or immediately prior to each case resulting in VTE. Pre- and perioperative data were collected with respect to demographics, past medical history, medications, and surgical and anesthesia data. Chemoprophylaxis was not routinely used. RESULTS: 12,595 patients underwent knee arthroscopy during the study period. 43 cases of VTE (35 deep vein thromboses [DVT], 5 pulmonary embolisms [PE], and 3 DVTs that progressed to PE) occurred in 12,595 knee arthroscopy procedures, resulting in an incidence of 0.30% (95% CI 0.22-0.41%) for DVT, and 0.06% (95% CI 0.03-0.12%) for PE. Factors associated with an elevated risk of postoperative VTE included history of malignancy (p = 0.01), history of prior VTE (p = 0.02; OR = 8.9), and the presence of ≥ 2 classic risk factors for VTE (p = 0.04;OR = 2.66). CONCLUSIONS: VTEs occur in 0.34% of knee arthroscopy cases in the absence of routine chemoprophylaxis. Patients with a history of VTE, malignancy, or 2 or more classic risk factors are at increased risk for VTE after knee arthroscopy. 5. Reverse Shoulder Arthroplasty for Instability After Anatomic Arthroplasty *Matthew B. Abdel, M.D. Rochester, MN Steven J. Hattrup, M.D. Scottsdale, AZ John W. Sperling, M.D. Rochester, MN Robert H. Cofield, M.D. Rochester, MN Cole R. Kreofsky, B.S. Rochester, MN Joaquin Sanchez-Sotelo, M.D. Rochester, MN INTRODUCTION: Instability after shoulder arthroplasty is difficult to correct. Reverse shoulder arthroplasty represents an attractive option. However, the results of such procedures are largely unknown. The purpose of this study was to determine the results of revision of the unstable anatomic shoulder arthroplasty to a reverse prosthesis. METHODS: Between 2004 and 2007, 33 unstable anatomic shoulder arthroplasties were revised to a reverse design. Outcomes evaluated included visual analog scores (VAS) for pain, range of motion, Neer rating, and shoulder stability. The mean age was 71 years, with 58% of the patients being female. The average follow-up was 26 months. RESULTS: The average time from the index arthroplasty to revision was 26 months (range, 4- 164 months).