ABSTRACTS Purpose: Arthroscopy of the knee is commonly performed as an outpatient surgical procedure. Effective post-operative pain management continues to be a challenging problem. Previous studies have addressed post-operative management by examining use of intraarticular analgesia and/or modification of anesthesia techniques. No previous studies have however, evaluated the relationship between sleep deprivation and post-operative pain. The purpose of this study was to evaluate the effectiveness of a non-benzodiazepine hypnotic sleep-aid (Zolpidem) in improving post-operative pain management in patients undergoing outpatient knee arthroscopy. Methods: Patients undergoing outpatient knee arthroscopy for treatment of meniscal tears and/or loose bodies were randomized to three treatment groups (AMBIEN, NONE, and PLACEBO). All groups received post-operative hydrocodone and ibuprofen. Patients in the AMBIEN groups received a single dose of oral zolpidem for the first seven post-operative nights. Patients in the placebo group received a gelatin capsule similar in appearance to zolpidem. Results: Patients in the NONE group and PLACEBO group (no zolpidem received) demonstrated consistently worse pain scores on a visual analog scale. Furthermore, patients who did not receive zolpidem consumed higher quantities of acetaminophen/hydrocodone post-operatively. Conclusion: This study demonstrates that sleep and fatigue may be an important factor in the effective management of pain after outpatient knee arthroscopy. Future therapy should address sleep and fatigue in order to maximize analgesic effects in these patients.
Treatment of Degenerative Arthritis of the Knee in a Younger, Athletic Patient Population with Intra-articular Hylan G-F 20 Injections (SS-14). Jonathan E. Mack, MD, Harlan Selesnick, MD, Jeremy Stevens, MD Purpose: To demonstrate that Hylan G-F 20 injections in younger, athletic populations with degenerative arthritis of the knee reduce pain and allow resumption of sporting lifestyles. Methods: Forty-six patients under age 59 with symptomatic degenerative arthritis of the knee and a history of impaired sports participation were prospectively followed after injections with Hylan G-F 20. Degenerative arthritis of the knee was confirmed by x-ray, MRI, and/or arthroscopic evaluations. Each patient received weekly Hylan G-F injections for a total of three weeks. Patients completed IKDC and Womac knee evaluation forms at
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the time of their first injections, and also after 3, 6, and 12 months after their primary injections. Results: The average age of the patients in this study was 47, with a range of 29 to 58 years. Analysis of the IKDC and Womac scores at zero and three months after injection revealed significant improvement (p ⬍ 0.05) in patient function and pain (42.9 to 55.0, and 70.1 to 82.7 respectively). Patients experienced substantially higher levels of athletic activity on both a peak and daily basis when comparing IKDC data at 0 versus 3 months post initial injection (p ⬍ 0.001). Sports participation and function improved approximately one full level for patients during this interval. Conclusion: The use of Hylan G-F 20 injections is an effective means of improving pain and function in younger, athletic populations with degenerative arthritis of the knee. Of note, patients experienced marked improvement in their ability to participate in sports with a coinciding decrease in symptoms involving the knee. Arthroscopic Shoulder Synovectomy in Patients With Rheumatoid Arthritis (SS-15). Adam M. Smith, MD, John W. Sperling, MD, Shawn W. O’Driscoll, PhD, MD, Robert H. Cofield, MD Arthroscopic shoulder synovectomy in patients with rheumatoid arthritis with an intact rotator cuff offers reliable decrease in pain with less predictable improvements in range of motion. Pain improved in thirteen of sixteen shoulders (p⬍0.001). Active shoulder elevation improved from a median of 145 to 160 degrees but was not significant (p⫽0.14). Limitations in predicting final results based on preoperative radiographs should be discussed with patients. Purpose: Currently, there is little information available concerning the results of shoulder synovectomy in patients with rheumatoid arthritis. Therefore, we reviewed our experience with synovectomy in patients with rheumatoid arthritis with an intact rotator cuff to determine the results of treatment. Methods: Sixteen shoulders in thirteen patients with rheumatoid arthritis were treated with arthroscopic shoulder synovectomy from 1988 to 2002 with a mean follow-up of 5.5 years. Patients with full thickness rotator cuff tears or partial tears that required repair were excluded. Two of the thirteen patients had been diagnosed with juvenile rheumatoid arthritis, and eleven had adult onset disease. Patients were reviewed to assess pain, satisfaction, range of motion, and radiographic outcomes. Results: Pain improved in thirteen of sixteen shoulders (p⬍0.001). Active shoulder elevation improved
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ABSTRACTS
from a median of 145 to 160 degrees but was not significant (p⫽0.14). External rotation improved significantly (p⫽0.01) from a median of 45 to 60 degrees. There were five excellent, eight satisfactory, and three unsatisfactory results. Seven of eight shoulders followed radiographically for greater than one year demonstrated radiographic progression of disease. All three patients reporting pain that was no better or worse than before surgery had radiographic arthrosis at last follow-up with advancing periarticular erosions and reduction of glenoid articular space. Discussion: Arthroscopic shoulder synovectomy in patients with rheumatoid arthritis with an intact rotator cuff offers reliable decrease in pain with less predictable improvements in range of motion. Limitations in predicting final results based on preoperative radiographs should be discussed with patients.
acromial arthroscopic surgery and cadaveric dissection were conducted. A vascular map of the bursa was created. Results: The vascular supply of the subacromial structures showed consistent patterns of distribution and bleeding points were catalogued and mapped. Findings were as follows: Anterior wall: Acromial branch of the thoracoacromial artery. Posterior wall: Acromial branch of the suprascapular artery. Medial wall: Anterior and posterior arteries of the AC joint. Lateral wall: No major arteries identified. Vascular mapping of the roof and floor is also described. Conclusion: The subacromial space of the shoulder is highly vascular. Mapping of the vascular anatomy and knowledge thereof may decrease the bleeding during subacromial arthroscopic surgery, as the surgeons is alert to high risk areas.
Vascular Antaomy of the Subacromial Space: A Map of Bleeding Points for the Arthroscopic Surgon (SS16). Horacio Yepes, MD, William D. Stanish, MD, Maolin Tang, MD, Steven Morris, MD, Amro Al-hibshi, MD
Arthroscopic Treatment of Glenohumeral Arthritis with Interpositional Grafting (SS-17). David Argo, MD, Felix H. Savoie, III, MD, Larry D. Field, MD
Arthroscopic surgery about the shoulder may pose risk to vascular structures. Bleeding during such surgery complicates the technical procedure. A detailed anatomical map of bleeding points is desired in order to properly identify these high risk areas. The purpose of this study is to map the vascular anatomy of the subacromial space, providing forewarning to the surgeon. The subacromial space of the shoulder is highly vascular. Mapping of the vascular anatomy and knowledge thereof may decrease the bleeding during subacromial arthroscopic surgery, as the surgeons is alert to high risk areas. Background: Arthroscopic surgery about the shoulder may pose risk to vascular structures. Bleeding during such surgery complicates the technical procedure. A detailed anatomical map of bleeding points is desired in order to properly identify these high risk areas, and thus avoid an unnecessary complication which can cause surgical morbidity. The purpose of this study is to map the vascular anatomy of the subacromial space, providing forewarning to the surgeon. Methods: Ten shoulders of five adult cadavers underwent whole body arterial perfusion with a mixture of lead oxide, gelatin and water. The specimens were dissected, photographed and radiographed. The cadaveric shoulders were then scanned and analyzed with a digital software tool. Meticulous dissection of the different arteries of the subacromial space and anatomical landmarks of the boundaries (the subacromial space) were documented. Correlations of bleeding areas during sub-
Purpose: The treatment of glenohumeral arthritis is a challenge for the relatively young and active patient. Traditional arthroplasty has demonstrated acceptable results in the treatment of the arthritic shoulder. Questions remain about the best option for the younger more active patient. This study was design to evaluate the efficacy of arthroscopic interpositional graft arthroplasty as an alternative to hemi or total shoulder arthroplasty. Methods: Twenty patients met our inclusion criteria: 1) clinical and radiographic evidence of advanced glenohumeral arthritis 2) maintenance of the spherical shape of the humeral head 3) failure of non-operative treatments including: NSAIDS, steroid injections, and physical therapy 4) desire to avoid arthroplasty. These twenty patients underwent arthroscopic interpositional grafting of the glenoid with a porcine xenograft (Restore patch). Preoperative and postoperative range of motion and VAS pain scores were recorded in all twenty patients. Post operative MRIs were obtained in 17 patients. Three patients could not undergo magnetic evaluation. Results: The average age was 53.6 years (16-83). The average follow-up was 13 months (5-37). Range of motion improved from preoperative flexion of 90 degrees to 150 degrees, abduction from 70 degrees to 120 degrees, and VAS improved from 8 preoperatively to 2 postoperatively. Eighty-five percent of patients reported good or excellent overall results and all had dramatic relief of pain. MRI results demonstrated maintenance of joint space in all patients.