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OBJECTIVES Perioperative fascia iliaca regional anesthesia (FIRA) decreases pain in hip fracture patients. The purpose of this study is to determine which hip fracture types and surgical procedures benefit most. DESIGN Prospective observational study compared with a retrospective historical control. PATIENTS/PARTICIPANTS Patients older than 60 years who received perioperative FIRA were compared with a historical cohort not receiving FIRA. SETTING This study was conducted at a Level 1 trauma center. MAIN OUTCOME MEASUREMENTS The primary outcome was morphine milliequivalents (MME) consumed during the index hospitalization. Fracture pattern-specific preoperative and postoperative MME consumption and surgical procedure-specific postoperative MME consumption was compared between the FIRA and non-FIRA groups. RESULTS A total of 949 patients were included in this study, with 194 (20.4%) patients in the prospective protocol group. There were no baseline differences between cohorts. Preoperatively, only femoral neck fracture patients receiving FIRA used fewer MME (P < 0.001). Postoperatively, femoral neck fracture patients receiving FIRA used fewer MME on postoperative day (POD) 1 (P = 0.027) and intertrochanteric fracture patients used fewer MME on POD1 and POD2 (P = 0.013; P = 0.002). Cephalomedullary nail patients receiving FIRA used fewer MME on POD1 and POD2 (P = 0.004; P = 0.003). Hip arthroplasty patients receiving FIRA used fewer MME on POD1 (P = 0.037). Percutaneous pinning and sliding hip screw patients had no significant MME reduction from FIRA. CONCLUSIONS Preoperatively, patients with femoral neck fractures benefit most from FIRA. Postoperatively, both patients with femoral neck fractures and intertrochanteric fractures benefit from FIRA. Patients undergoing cephalomedullary nail fixation or hip arthroplasty benefit most from FIRA postoperatively. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background Geriatric hip fracture patients are susceptible to the adverse effects of opioid-induced analgesia. Fascia iliaca blocks (FIBs) have emerged as an analgesic technique for this population. There are limited data on a preoperative FIB's effect on perioperative opioid intake. We hypothesized that preoperative FIB would reduce perioperative opioid consumption, measured in morphine milliequivalents (MMEs). Design This is a prospective observational study. Setting A level 1 trauma center in California. Participants From March 2017 to December 2017, patients 65 years and older presenting with a hip fracture received a preoperative FIB and were prospectively observed. This cohort was compared with a historical control. Intervention All prospectively enrolled patients were given FIBs. For a single-shot FIB, a 30- to 40-mL bolus of 0.25% bupivacaine with 1:200,000 epinephrine was injected. For a continuous FIB, a bolus of 10 to 20 mL of 0.2% bupivacaine was injected, followed by a continuous infusion of 0.2% bupivacaine at 6 mL/h ending on the morning of postoperative Day 1. Results A total of 725 patients were included in this study, with 92 in the prospectively collected cohort. The mean age of this cohort was 84.2 (standard deviation = 8.4) years, and 69.2% were female. Patients who received a preoperative FIB consumed less MME preoperatively, 18.0 (interquartile range = 6.0-44.5) versus 29.5 (interquartile range = 6.0-56.5) (P = .007), with no change in pain scores. No differences were found in postoperative opioid consumption between groups. There was no difference in MME or pain score in patients with dementia. Subgroup analysis based on fracture pattern (femoral neck and intertrochanteric) demonstrated a significant decrease in preoperative MME consumption in femoral neck fractures only, 12.0 (interquartile range = 5.0-24.0) versus 29.0 (interquartile range = 12.0-59.0) (P Conclusion FIBs reduce preoperative opioid intake and have low rates of opioid-related adverse events in geriatric hip fracture patients. Level of evidence The level of evidence was II.

BACKGROUND Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events. METHODS This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB. RESULTS There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay. CONCLUSIONS Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND Two popular physeal-sparing procedures used in the management of anterior cruciate ligament (ACL) injuries in skeletally immature patients are the iliotibial band (ITB) ACL reconstruction (ACLR) and the all-epiphyseal (AE) ACLR. Although there has been concern for overconstraint of the lateral compartment of the knee with the ITB ACLR technique, rotational stability, as provided by the anterolateral ligament (ALL) and ACL, has not been assessed in the setting of pediatric ACLR techniques. Our hypothesis is that the ITB ACLR and AE ACLR with ALL reconstruction (ALLR) will best replicate the biomechanical profile of the intact ACL that is lost with transection of the ACL and ALL. METHODS Eight cadaveric legs were statically loaded with an anterior drawer force and varus, valgus, internal and external rotational moments at 0, 30, 60, and 90 degrees of flexion. Displacement and rotation were recorded in the following conditions: intact ACL/intact ALL, ACL-deficient/intact ALL, ITB ACLR/intact ALL, ITB ACLR/ALL-deficient, ACL-deficient/ALL-deficient, AE ACLR/ALL-deficient, AE ACLR/ALLR. RESULTS Both ACLR techniques reduced anterior tibial translation from the ACL-deficient state, but neither restored it to the intact state (P

Fascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks.We performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates.107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups.We report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.

Background: A hamstring autograft is commonly used in anterior cruciate ligament (ACL) reconstruction (ACLR); however, there is evidence to suggest that the tendons harvested may contribute to medial knee instability. Hypothesis: We tested the hypothesis that the gracilis (G) and semitendinosus (ST) tendons significantly contribute to sagittal, coronal, and/or rotational knee stability in the setting of ACLR with a concurrent partial medial collateral ligament (MCL) injury. Study Design: Controlled laboratory study. Methods: Twelve human cadaveric knees were subject to static forces applied to the tibia including an anterior-directed force as well as varus, valgus, and internal and external rotation moments to quantify laxity at 0°, 30°, 60°, and 90° of flexion. The following ligament conditions were tested on each specimen: (1) ACL intact/MCL intact, (2) ACL deficient/MCL intact, (3) ACL deficient/partial MCL injury, and (4) ACLR/partial MCL injury. To quantify the effect of muscle loads, the quadriceps, semimembranosus, biceps femoris, sartorius (SR), ST, and G muscles were subjected to static loads. The loads on the G, ST, and SR could be added or removed during various test conditions. For each ligament condition, the responses to loading and unloading the G/ST and SR were determined. Three-dimensional positional data of the tibia relative to the femur were recorded to determine tibiofemoral rotations and translations. Results: ACLR restored anterior stability regardless of whether static muscle loads were applied. There was no significant increase in valgus motion after ACL transection. However, when a partial MCL tear was added to the ACL injury, there was a 30% increase in valgus rotation ( P < .05). ACLR restored valgus stability toward that of the intact state when the G/ST muscles were loaded. A load on the SR muscle without a load on the G/ST muscles restored 19% of valgus rotation; however, it was still significantly less stable than the intact state. Conclusion: After ACLR in knees with a concurrent partial MCL injury, the absence of loading on the G/ST did not significantly alter anterior stability. Simulated G/ST harvest did lead to increased valgus motion. These results may have important clinical implications and warrant further investigation to better outline the role of the medial hamstrings, particularly among patients with a concomitant ACL and MCL injury. Clinical Relevance: A concurrent ACL and MCL injury is a commonly encountered clinical problem. Knowledge regarding the implications of hamstring autograft harvest techniques on joint kinematics may help guide management decisions.

The traditional technique for patella fracture fixation utilizes prominent hardware. Prominent hardware use, however, results in a high rate of reoperation for symptomatic implant removal. This biomechanical study evaluates the effectiveness of a novel patella fixation technique that minimizes implant prominence. Patellar transverse osteotomies were created in 13 pairs of cadaveric knees. Paired knees were assigned to either standard fixation (SF) using cannulated partially threaded screws and stainless steel wire tension band, or buried fixation (BF) using headless compression screws with a No. 2 FiberWire tension band and a No. 5 FiberWire cerclage suture. Quadriceps tendons were cyclically loaded to full extension followed by load to failure. The gap across the fracture site, stiffness, and load to failure were measured. The differences in stiffness and load to failure between the 2 groups were not statistically significant. During cyclic loading, significantly greater gapping was observed across the fracture site in the BF group compared with SF group (P < .05). Both constructs failed under loads that exceeded typical loads experienced during the postoperative rehabilitation period. Nevertheless, the BF technique demonstrated larger gap formation and a reduced load to failure than the SF technique. Further clinical studies are therefore underway to determine whether the use of constructs with decreased stability but increased patient comfort could improve clinical outcomes and reduce reoperation rates.

Objectives: Management of anterior cruciate ligament (ACL) injuries in skeletally immature patients is controversial and several surgical procedures have been developed. The two most popular physeal sparing procedures are the iliotibial band (ITB) ACL reconstruction (ACLR) and the all-epiphyseal (AE) ACLR. There has been some concern for over-constraint of the knee with the ITB ACLR while the AE ACLR is technically challenging and can still risk growth disturbance. There has been interest recently into the anterolateral ligament (ALL) and its role in rotational stability, but it has not been assessed in the setting of pediatric ACLR techniques. The ITB ACLR includes a lateral tenodesis of the IT band to the femur that closely approximates the ALL. Our hypothesis is that the ITB ACLR and AE ACLR with ALL reconstruction (ALLR) will best replicate the biomechanics profile of the intact ACL. Methods: Eight cadaveric legs were statically loaded with an anterior drawer force and varus, valgus, internal and external rotational moments at 0°, 30°, 60°, and 90° of flexion. Displacement and rotation was recorded in the following conditions: intact ACL/intact ALL, ACL deficient/intact ALL, ITB ACLR/intact ALL, ITB ACLR/ALL deficient, ACL deficient/ALL deficient, AE ACLR/ALL deficient, AE ACLR/ALLR. Results: Both ACLR techniques reduced anterior translation from the ACL deficient state but neither restored translation to the intact state (pConclusion: In this model, the ITB ACLR best corrected both parameters at all angles without over-constraining the knee and without the need for an ALLR. The AE ACLR and AE ACLR/ALLR improved both parameters but not at all flexion angles. The ITB ACLR appears to be the simpler pediatric ACLR technique to regain translational and rotational stability. ALL deficiency in the knee increased anterior displacement and rotational moments in the ACL deficient state.

Objectives: Hamstrings autograft is commonly used to reconstruct an isolated ACL tear, however, there is evidence to suggest that the tendons harvested may contribute to medial knee stability. We tested the hypothesis that the gracilis (G) and semitendinosus (St) tendons significantly contribute to sagittal, coronal and/or rotational knee stability in the setting of an ACL reconstruction with concurrent partial MCL injury. Methods: Twelve human cadaveric knees were subject to a static anteriorly-directed force and moments in varus, valgus, internal and external rotation at the tibia while the femur was held stationary in order to quantify laxity at 0, 30, 60, and 90 degrees of flexion. Testing was performed on each leg in following ligament conditions: (1) ACL-intact/MCL-intact, (2) ACL-deficient/MCL-intact, (3) ACL-deficient/ MCL-partial injury, and (4) ACL-reconstruction, MCL-partial injury (chart 1). To quantify the effect of muscle loads the quadriceps, semimembranosus, biceps femoris, sartorius (Sr), St and G muscles were sutured and physiologically loaded. Quadriceps were loaded to 200 N and semimembranosus and biceps femoris were loaded to 40 N and held constant for all test conditions. The G and St were attached to a 40N load which was removed during test conditions in order to simulate hamstring graft harvest. Similarly, a Sr load of 20N was added and removed to determine its role in contributing to knee stability. For each ligament condition, the response to loading was determined with either (A) St/G muscles loaded and Sr unloaded; (B) St/G loaded, Sr loaded; (C) St/G unloaded, Sr unloaded; and (D) St/G unloaded, Sr loaded (chart 1). Three-dimensional positional data of the tibia relative to the femur was recorded to determine displacement and rotation across the knee. Results: ACL reconstruction restored anterior stability regardless of whether or not G/St and/or Sr loads were applied. A partial tear of the MCL significantly increased external rotation when the G/St were unloaded and approached significance (pConclusion: Absence of load on the G and St, as would be the case when harvested for hamstrings autograft, did not lead to increased anterior translation of the tibia in ACL reconstructed knees with partial MCL injury. Although the absence of an applied G and St muscle force did lead to increased valgus rotation after ACL reconstruction, there was no difference between the G/St loaded state compared to the G/St unloaded state once a Sr load was applied. This may have clinical implications for surgeons with regard to post-operative bracing and ACL reconstruction graft recommendations. [Figure: see text]

Background: Relatively little information exists regarding the public’s perception of anterior cruciate ligament (ACL) injuries and their treatment. The objective of this study was to test the hypothesis that the public’s understanding of ACL surgery may be incorrect with regard to various aspects of this procedure and to identify issues to emphasize in patient education. Methods: This study utilized a forty-three-question survey designed to measure an individual’s knowledge base and perception of ACL reconstruction with regard to the anatomy, function, indications, operative technique, risks, recovery time, and overall benefits of the procedure. Eligible individuals were between fifteen and sixty years of age. Study participants were recruited from an academic orthopaedic sports medicine clinic, a collegiate athletic training room, and various public venues. Results: A total of 210 individuals (106 men and 104 women) with a mean age of thirty were surveyed. Educational level of the respondents varied widely. Twenty-seven percent of the respondents were employed in a health-care setting. Sixty-five percent of the respondents rated their ACL knowledge level as “little” or “none.” Participants’ self-perception of ACL knowledge was highly correlated with their survey scores on questions with a specific correct answer (p < 0.001). Almost one-third thought that surgical treatment involved repair of the torn ligament rather than reconstruction. Over half (56%) of the respondents preferred an autograft for ligament reconstruction, compared with 4% who preferred an allograft. The ability to return to sports after ACL surgery was the most important concern, followed by the risk of developing osteoarthritis. Conclusions: There is wide variability in the lay public’s knowledge level of ACL injuries; a substantial number of misguided perceptions were identified. Return to sports and risk for future osteoarthritis following ACL surgery appear to be the most important factors to the lay public. Focusing educational efforts on areas of knowledge deficits may be particularly important for patients of physicians who treat ACL injuries.