Functional results and outcomes after repair of proximal hamstring avulsions.

BACKGROUND: The purpose of this study was to assess postsurgical outcomes in active patients after primary repair of acute and chronic proximal hamstring tears. HYPOTHESIS: Surgical treatment of both acute and chronic proximal hamstring avulsion injuries would result in improved patient outcomes using validated outcome scores and a hamstring-specific questionnaire, and operative repair of these injuries results in excellent outcomes with a high level of patient satisfaction, pain relief, and return to function. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Fifty-two patients who underwent proximal hamstring repair (26 male and 26 female; average age, 47.7 years) completed the Lower Extremity Functional Scale (LEFS), a custom LEFS, the Marx Activity Scale, a custom Marx scale, a proximal hamstring score (which combines the sum of the custom LEFS and Marx), and a proximal hamstring questionnaire with subjective questions. Forty patients were characterized as having acute repairs, and 12 patients had chronic repairs. All patients underwent surgical repair with 5 suture anchors on the ischial tuberosity through a transverse incision. The rehabilitation protocol was also similar with the use of a hip orthosis for 6 to 8 weeks, allowing progressive weightbearing and range of motion. RESULTS: The mean follow-up in our study was 33 months (range, 12-76 months). The mechanism of injury in 28 patients was eccentric hip flexion and knee extension in the ipsilateral knee typically caused by a slip and fall accident. One patient\u27s injury was caused by trauma to the proximal hamstring. In 23 patients, hamstring injuries were sports related. Overall, 51 (98%) were satisfied with their outcome after surgery. The LEFS, Marx, custom LEFS, custom Marx, and proximal hamstring scores for patients with acute injuries were 76.2, 10.0, 71.4, 20, and 91.7, respectively. For those with chronic injury, the scores were 71.5, 10.4, 70.8, 18.7, and 89.8, respectively. The scores were not statistically different for LEFS, Marx, custom LEFS, and proximal hamstring scores (P = .22, P = .6, P = .72, and P = .6, respectively). Patients with acute injury did have a greater custom Marx score (P = .001). Postoperatively, 5 patients (9.6%) had burning pain or numbness in the posterior thigh or foot, and 25 (48%) had at least some discomfort sitting. Thirty-five patients (67%) reported they could participate in strenuous activities at their latest follow-up. All patients estimated their strength recovery at ≥75%. CONCLUSION: Results of this study indicate successful outcomes for both acute and chronic repairs, although patients with the acute repairs had higher functional and hamstring scores, and estimated hamstring strength

Revision total knee arthroplasty in the young patient: is there trouble on the horizon?

BACKGROUND: The volume of total knee arthroplasties, including revisions, in young patients is expected to rise. The objective of this study was to compare the reasons for revision and re-revision total knee arthroplasties between younger and older patients, to determine the survivorship of revision total knee arthroplasties, and to identify risk factors associated with failure of revision in patients fifty years of age or younger. METHODS: Perioperative data were collected for all total knee arthroplasty revisions performed from August 1999 to December 2009. A cohort of eighty-four patients who were fifty years of age or younger and a cohort of eighty-four patients who were sixty to seventy years of age were matched for the date of surgery, sex, and body mass index (BMI). The etiology of failure of the index total knee arthroplasty and all subsequent revision total knee arthroplasties was determined. Kaplan-Meier survival curves were used to evaluate the timing of the primary failure and the survivorship of revision knee procedures. Finally, multivariate Cox regression was used to calculate risk ratios for the influence of age, sex, BMI, and the reason for the initial revision on survival of the revision total knee arthroplasty. RESULTS: The most common reason for the initial revision was aseptic loosening (27%; 95% confidence interval [CI] = 19% to 38%) in the younger cohort and infection (30%; 95% CI = 21% to 40%) in the older cohort. Of the twenty-five second revisions in younger patients, 32% (95% CI = 17% to 52%) were for infection, whereas 50% (95% CI = 32% to 68%) of the twenty-six second revisions in the older cohort were for infection. Cumulative six-year survival rates were 71.0% (95% CI = 60.7% to 83.0%) and 66.1% (95% CI = 54.5% to 80.2%) for revisions in the younger and older cohorts, respectively. Infection and a BMI of ≥40 kg/m2 posed the greatest risk of failure of revision procedures, with risk ratios of 2.731 (p = 0.006) and 2.934 (p = 0.009), respectively. CONCLUSIONS: The survivorship of knee revisions in younger patients is a cause of concern, and the higher rates of aseptic failure in these patients may be related to unique demands that they place on the reconstruction. Improvement in implant fixation and treatment of infection when these patients undergo revision total knee arthroplasty is needed. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence

Ketamine for Refractory Headache: A Retrospective Analysis.

BACKGROUND AND OBJECTIVES: The burden of chronic headache disorders in the United States is substantial. Some patients are treatment refractory. Ketamine, an N-methyl-D-aspartate antagonist, provides potent analgesia in subanesthetic doses in chronic pain, and limited data suggest it may alleviate headache in some patients. METHODS: We performed a retrospective study of 61 patients admitted over 3 years for 5 days of intravenous therapy that included continuous ketamine to determine responder rate and patient and ketamine infusion characteristics. Pain ratings at 2 follow-up visits were recorded. An immediate responder was a patient with decrease of 2 points or greater in the numerical rating scale (0-10) from start to final pain in the hospital. Sustained response at office visits 1 and 2 was determined based on maintaining the 2-point improvement at those visits. Patients were assessed daily for pain and adverse events (AEs). RESULTS: Forty-eight (77%) of the 61 patients were immediate responders. There were no differences regarding demographics, opioid use, or fibromyalgia between immediate responders and nonresponders. Maximum improvement occurred 4.56 days (mean) into treatment. Sustained response occurred in 40% of patients at visit 1 (mean, 38.1 days) and 39% of patients at visit 2 (mean, 101.3 days). The mean maximum ketamine rate was 65.2 ± 2.8 mg/h (0.76 mg/kg per hour). Ketamine rates did not differ between groups. Adverse events occurred equally in responders and nonresponders and were mild. CONCLUSIONS: Ketamine was associated with short-term analgesia in many refractory headache patients with tolerable adverse events. A prospective study is warranted to confirm this and elucidate responder characteristics

The Use of Epoetin-α in Revision Knee Arthroplasty.

Introduction. To evaluate the efficacy of epoetin-α prior to revision total knee arthroplasty, we hypothesized that epoetin-α will reduce blood transfusion. Methods. Eighty-one patients were compared in this retrospective review; twenty-eight patients received our dosing regimen. All patients were mildly anemic. Epoetin-α to control (1 : 2) patient matching occurred so that one of two attending surgeons, gender, BMI, complexity of surgery, ASA score, and age were similar between groups. The clinical triggers for blood transfusion during or after the procedure were determined based on peri- and postoperative hemoglobin levels, ASA score, and/or clinical symptoms consistent with anemia. Blood salvage was not used. Results. Blood transfusion and length of stay were lower in the study group. None of the patients who received epoetin-α underwent transfusion. Hemoglobin increased from 11.97 to 13.8, preoperatively. Hemoglobin at day of surgery and time of discharge were higher. Gender, BMI, ASA score, total and hidden blood losses, calculated blood loss, preop PLT, PT, PTT, and INR were similar between groups. One Epogen patient had an uncomplicated DVT (3.6%). Conclusions. Epoetin-α may have a role in the mildly anemic revision knee patient. It may also decrease patient length of stay allowing for earlier readiness to resume normal activities and/or meet short-term milestones. A randomized study to evaluate the direct and indirect costs of such a treatment methodology in the mildly anemic revision patient may be warranted

The Use of Preoperative Epoetin-α in Revision Hip Arthroplasty

PURPOSE: To evaluate the efficacy of preoperative epoetin-α on the revision hip arthroplasty patient. We hypothesized that epoetin-α will reduce blood transfusion. A pertinent review of the literature is provided. METHODS: Forty-six patients were retrospectively reviewed. Sixteen patients received epoetin-α. Patients were case matched by age, preoperative hemoglobin, surgery, gender, and BMI. The clinical triggers for blood transfusion during or after the procedure were determined based on peri- and postoperative hemoglobin levels, ASA score, and/or clinical symptoms consistent with anemia. Blood salvage was not used. RESULTS: Blood transfusion and length of stay were decreased in the epoetin-α group. Hemoglobin in the intervention group increased from 12.0 to 14.5, preoperatively. Patients who received epoetin-α were 0.78 (RR=0.225) times as likely to receive a transfusion. Number Needed to Treat (NNT) to avoid one allogeneic transfusion was 1.84. Age, Gender, BMI, ASA, total and hidden blood loss, preoperative Iron supplements, preop Hct, preop PLT, PT, PTT, and INR were similar. One (6.0%) patient developed an uncomplicated deep venous thrombosis in the intervention group. CONCLUSIONS: The mildly anemic revision hip arthroplasty patient is at increased risk for transfusion. Epoetin-α increased preoperative hemoglobin counts and reduced transfusions in this study; it also decreased patient length of hospital stay likely allowing for an earlier readiness to resume normal activities and/or meet short-term milestones. A randomized study to evaluate the direct and indirect costs of such a treatment methodology in the mildly anemic revision patient may be warranted