Acute pain is one of the most common symptoms shared among patients who have suffered from an orthopedic trauma such as an isolated upper limb fracture (IULF). Development of interventions with limited side effects aiming to prevent the installation of chronic pain is critical as persistent pain is associated with an increased risk of opioid dependence, medical complications, staggering financial burdens and diminished quality of life. Theta burst stimulation (TBS), a non-invasive magnetic brain stimulation technique with minimal side effects, has shown promising results in patients experiencing various types of chronic pain conditions as it precisely targets brain regions involved in pain processing. Surprisingly, its impact on acute pain has never been investigated. This study aims to assess longitudinal effects of a 10-day continuous TBS (cTBS) protocol applied in the acute phase of an IULF on key functional outcomes. Patients with an IULF aged between 18 to 60 years old were recruited within 7 days post-accident at a Level I Trauma Center. Exclusion criteria included a history of brain injury, neurological disorders, musculoskeletal complications, and open fractures. In order to assess longitudinal changes, questionnaires measuring intensity and characteristics of pain (Numerical Rating Scale, NRS; McGill Pain Questionnaire, MPQ) as well as functional disability (DASH) were completed by all patients at three time points, namely prior to the start of the TBS program as well as 72 hours and 3 months post-intervention. Patients were randomly attributed to the active TBS protocol (active group) or to the placebo protocol (sham group). The stimulation site for each participant corresponded to the contralateral motor cortex of the injured arm. Fifty patients were recruited (female: 24; age: 40.38 years old), of which 25 were in the active group and 25 were in the sham group. Both groups were equivalent based on age, sex, type of injury, and surgical procedures (p>0.05). The intervention protocol was introduced on average 6.18 days post-accident. In comparison to the sham group, the active group showed a significant decrease in pain intensity (NRS) at 72h (F=6.02; p=0.02) and 3-month (F=6.37; p=0.02) post-intervention. No group difference was found early-on (72h post) in regard to pain characteristics (MPQ; F=3.90; p=0.06) and functional disabilities (DASH; F=0.48; p= 0.49). At three-month post-intervention, the active group showed statistically significant improvement on the MPQ (F=5.02; p=0.04) and the DASH (F=5.88; p=0.02) compared to the placebo group. No complications related to the treatment were reported. Results from this study show that patients who underwent active cTBS reported less pain and better functional states shortly after the end of the TBS protocol compared to sham patients and treatment effects were maintained at three months post-intervention. Given that acute pain intensity is an excellent predictor of chronic pain development, this safe technique available in numerous centers in Canada may help prevent chronic pain development when administered during the acute post-injury phase. Future studies should continue to investigate mechanisms involved to optimize this technique among the orthopedic trauma population and to reduce opioid consumption

Māori consistently have poorer health outcomes compared to non-Māori within Aotearoa. Numerous worldwide studies demonstrate that ethnic minorities receive less analgesia for acute pain management. We aimed to compare analgesic management of a common orthopaedic injury, tibial shaft fracture, between Māori and non-Māori. A retrospective cohort study from January 1. st. , 2015, to December 31. st. 2020 inclusive. Eligible patients were 16–65 years old and had isolated closed tibial shaft fractures. 104 patients were included in the study, 48 Māori and 56 Non-Māori. Baseline demographics were similar between the 2 cohorts. The primary outcome measure was type of analgesia charted on the ward. Secondary outcome measures were pre-hospital medications given, pain scores on arrival to the emergency department (ED) and the ward, time to analgesia in ED and type of analgesia given in ED. Statistics were calculated using Fisher's exact test, Pearson's chi-squared test or Wilcoxson's rank sum test as appropriate. No statistically significant differences were found in opiates or synthetics charted to Māori vs Non-Māori (83% vs 89% and 77% vs 88% respectively), opiates given in ED, time to analgesia in ED or ED and ward arrival pain scores. Of statistical significance is that Māori were less likely to receive pre-hospital medication compared to Non-Māori (54% vs 80% respectively, p=0.004). Māori were significantly less likely to receive pre-hospital pain medication compared to Non-Māori. However no other statistically significant findings were found when comparing pain scores, time to analgesia or type of pain relief charted for Māori vs non-Māori. The reasons for Māori receiving significantly less prehospital medication were not explored in this study and further investigation is required to reduce the bias that exists in this area

Introduction. Pain after trauma has received relatively little research attention compared with surgical techniques and functional outcomes, but is important to patients. We aimed to describe nerve dysfunction and pain characteristics using tibial fractures as a model. We hypothesized that early nerve dysfunction was associated with neuropathic and chronic pain. Materials and Methods. Adult patients with isolated open or closed tibial diaphyseal fractures were prospectively observed for 1-year in 5 Major Trauma Centres. Nerve dysfunction was assessed using Semmes-Weinstein monofilaments, acute pain with the visual numerical rating scale (VNRS), neuropathic pain with the doleur neuropathique-4 score and quality of life (QOL) using the EQ-5D score. Results. Of 77 included patients, twenty-six (33.8%) had Gustilo-Anderson grade II or worse injuries. Forty-six (63.0%) had operative repair; 0 operation notes reported nerve injury. Mean VNRS pain scores one week post-injury were 4.6/10 (SD 2.4). Seventeen patients (23.3%) presented with impaired sensation, persisting in 11 (15.1%) at 3-months. Neuropathic pain affected 16 (20.8%) patients one week post-injury; a further 20 (26.0%) had >2 symptoms of nerve pain. Only four (11.1%) received anti-neuropathic drugs. At 6-months, twenty-three (31.5%) reported mobility problems, 21 (28.8%) difficulty completing normal activities, 25 (34.2%) pain and 15 (20.5%) anxiety and depression. Conclusions. Nerve dysfunction and neuropathic pain are common early features in patients with tibial fractures, but are poorly recognised and inadequately treated. Pain has long-term effects on patients’ QOL. Future work should aim to improve identification and management of neuropathic pain

Perioperative glucocorticoids have been used as a successful non-opioid analgesic adjunct for various orthopaedic procedures. Here we describe an ongoing randomized control trial assessing the efficacy of a post-operative methylprednisolone taper course on immediate post-operative pain and function following surgical distal radius fixation. We hypothesize that a post-operative methylprednisolone taper course following distal radius fracture fixation will lead to improved patient pain and function. This study is a randomized control trial (NCT03661645) of a group of patients treated surgically for distal radius fractures. Patients were randomly assigned at the time of surgery to receive intraoperative dexamethasone only or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course. All patients received the same standardized perioperative pain management protocol. A pain journal was used to record visual analog pain scores (VAS-pain), VAS-nausea, and number of opioid tablets consumed during the first 7 post-operative days (POD). Patients were seen at 2-weeks, 6-weeks, and 12-weeks post-operatively for clinical evaluation and collection of patient reported outcomes (Disabilities of the Arm, Shoulder and Hand Score [qDASH]). Differences in categorical variables were assessed with χ2 or Fischer's exact tests. T-tests or Mann-Whitney-U tests were used to compare continuous data. Forty-three patients were enrolled from October 2018 to October 2019. 20 patients have been assigned to the control group and 23 patients have been assigned to the treatment group. There were no differences in age (p=0.7259), Body Mass Index (p=0.361), race (p=0.5605), smoking status (p=0.0844), or pre-operative narcotic use (p=0.2276) between cohorts. 83.7% (n=36) of patients were female and the median age was 56.9 years. No differences were seen in pre-operative qDASH (p=0.2359) or pre-operative PRWE (p=0.2329) between groups. In the 7 days following surgery, patients in the control group took an average of 16.3 (±12.02) opioid tablets, while those in the treatment group took an average of 8.71 (±7.61) tablets (p=0.0270). We see that significant difference in Opioid consumption is formed at postoperative day two between the two groups with patients in the control group taking. Patient pain scores decreased uniformly in both groups to post-operative day 7. Patient pain was not statistically from POD0 to POD2 (p=0.0662 to 0.2923). However, from POD4 to POD7 patients receiving the methylprednisolone taper course reported decreased pain (p=0.0021 to 0.0497). There was no difference in qDASH score improvement at 6 or 12 weeks. Additionally, no differences were seen for wrist motion improvement at 6 or 12 weeks. A methylprednisolone taper course shows promise in reducing acute pain in the immediate post-operative period following distal radius fixation. Furthermore, although no statistically significant reductions in post-operative opioid utilization were noted, current trends may become statistically significant as the study continues. No improvements were seen in wrist motion or qDASH and continued enrollment of patients in this clinical trial will further elucidate the role of methylprednisolone for these outcomes

Chronic postsurgical pain (CPSP) can occur after elective mid/hindfoot and ankle surgery. Effective treatment approaches for CPSP in this population have not been extensively investigated. The impact of multimodal strategies on CPSP following elective mid/hindfoot surgery is unknown due to both the heterogeneity of acute pain management and the lack of a recognized definition specific to this type of surgery. This study aimed to identify and evaluate current pain management strategies after elective mid/hindfoot and ankle surgery. We conducted a systematic review under Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three databases (MEDLINE, Embase and Cochrane Library) were electronically searched for English studies published between 1990 and July 2017. Reference lists of relevant systematic reviews were also manually searched. Comparative studies of adults undergoing elective mid/hindfoot and ankle surgery were included. Two reviewers independently reviewed studies and assessed their methodological quality. Of 1,159 studies, seven high-quality randomized controlled trials met our inclusion criteria. Though all studies examined regional anesthesia techniques, intervention heterogeneity precluded meta-analysis. Participants were typically followed up to 48 hours post-operatively. Interventions effective at reducing postoperative pain and/or opioid consumption included inserting popliteal catheters under ultrasound instead of nerve stimulation guidance, infusing perineural dexamethasone, bupivacaine, or ropivacaine perioperatively, and adding a femoral catheter infusion to a popliteal catheter infusion. Only one study assessed pain six months following elective mid/hindfoot and ankle surgery, demonstrating significant pain reduction with activity with the addition of a femoral to popliteal catheter infusion. There is an overwhelming lack of evidence regarding CPSP and its management for patients undergoing elective mid/hindfoot and ankle surgery. Although specific regional anesthesia techniques and adjuncts may be effective at reducing in-hospital pain and opioid consumption after elective mid/hindfoot and ankle surgery, our systematic review identified only seven studies addressing multimodal pain management in this population. Further comparative studies with longer-term follow-up are required

We performed a randomized feasibility trial to examine the impact of preoperative femoral nerve block (FNB) on elderly patients with hip fractures, including those with mild to moderate cognitive impairment. We evaluated the impact of preoperative FNB on the following outcomes within 5 days of surgical fixation: 1. Pain levels, 2. Total narcotic consumption, 3. Postoperative mobilization. Randomized allocation of 73 patients in a 2:1 intervention:control ratio. To allow comparison between the 2 groups as well as sub- analysis of the intervention group to examine treatment fidelity (i.e. the ability to deliver the intervention as planned). Inclusion criteria: Patient age≥ 65 years admitted with a low energy hip fracture, ambulatory preinjury, Mini Mental State Exam MMSE score≥13 (moderate dementia), Able to provide direct or proxy consent. Exclusion criteria: Admission ≥ 30 hours after injury, prior regular use of opiates. Potential participants were identified and either participants or proxy respondents provided signed informed consent. Participants allocated to the intervention group received a FNB administered by the UAH acute pain service (APS) within 20 hours of admission to hospital in addition to the usual care. Participants in the control group received usual care. Participants were followed for 5 days postoperatively with daily assessment of pain, narcotic consumption, delirium and mobility. Main outcome measure: (1) Pain at rest and activity (2) Preoperative and postoperative opioid consumption, (3) Mobilization in POD#1. Overall, 73 participants were enrolled (23 Control: 50 FNB). The FNB group was slightly older (mean [SD] 80.1 [8.7] vs. 76.2 [9.2], p=0.09) and had more males (21 [42%] vs. 5 [22%], p=0.09) than the Control group. The mean MMSE score for both groups was >24 (p=0.35 for group comparison), suggesting minimal cognitive impairment of participants. The FNB group reported significantly less pain at rest and activity than the control group over time (p < 0 .001 for both). Opioid consumption were non-significantly higher and more variable in the control group preoperatively (Median [25, 75 quartile] 10.6 [0, 398] vs 7.5 [0, 125], p=0.26) and postoperatively (13.1 [0, 950] vs 10 [0, 260], p=0.31). 41 (85%) of FNB participants mobilized on day 1 vs. 16 (73%) of control participants (p=0.21). Preoperative FNB significantly reduced pain. Opioid consumption was not significantly different, but more variable in the control group. Although not significant, more FNB patients successfully mobilized on day 1 postoperatively. Participants with cognitive impairment were not enrolled due to difficulty in obtaining proxy consent. A definitive randomized trial would be feasible and add valuable information about pain management following hip fracture

Objective. We have been using continuous epidural block and local infiltration cocktail for the pain management after TKA since 2005, and good pain control has been acquired with this method. During the past few years we have changed our protocol of postoperative pain management. We have stopped the administration of Loxoprofen starting next morning of the operation, instead Celecoxib was given starting before the operation. We have started mixing steroid to the intraoperative local infiltration cocktail to reduce acute pain as well as swelling. We also have stopped using suction drain, and delayed the timing of CPM start from day 2 to day 3. Methods. This is case control study, and 78 cases of unilateral TKA were investigated for the study. All cases were anesthetized with continuous epidural block with intravenous dosage of phentanyl and propofol. Compositions of local infiltration cocktail are 40ml 0.75% Ropivacaine, 60ml saline, 0.5ml epinephrin. Group1 (n=40) used this cocktail independently, and Group2 (n=38) used this cocktail with addition of 40mg of triamcinolone(Fig.1). Local infiltration cocktail was used during operation, which was injected to the whole joint capsule. In group1 Loxoprofen was given starting next morning, in group 2 Celecoxib was given starting at 7am on the day of operation. In group1 suction tube was left for 2 days, where as in group2 no suction tube was used postoperatively, and continuous epidural block catheter was removed on postoperative day 2 in both groups. CPM was started at postoperative day 2 in group 1 and postoperative day 3 in group 2. Numerical Rating Scale (NRS) was used to analyze the pain. Circumferences of knee and thigh, as well as ROM of knee joint were measured periodically. Results. Preoperative demographics showed no statistical difference between two groups(Fig. 2). Group 2 showed significantly less pain at 6am next morning postoperatively (Fig.3&4). Group 2 showed significantly lower NRS on motion at postoperative day1, 3, 5 and 7 (Fig.5). Group 2 also showed significantly less swellings of knees and thighs at postoperative day 7 (Fig.6). The ROM of the knee joints at postoperative day 7, 14 and 21 were better in group2(Fig.7). Discussions. Our new method of multimodal pain control is effective. It significantly decreased the pain at 6am next morning postoperatively, which is due to preoperative administration of Celecoxib. The pain on motion during 1 st week was significantly decreased which is probably due to the addition of steroid to the cocktail. Suction drain was not needed, if you use steroid in the cocktail and delay the timing to start CPM. The swelling was significantly reduced by steroid injection and delay in ROM exercise. As a result better ROM at postoperative day 7,14 and 21 were obtained. To view tables/figures, please contact authors directly

Femoral component fracture is a rarely reported but devastating complication of total knee arthroplasty. It has occurred most frequently with Whiteside Ortholoc II replacements uncemented knee replacements. Presentation may be with acute pain, progressive pain or returning deformity. It occurs more commonly in the medial condyle of the femoral component. It is rarely seen in cemented replacements. All currently available literature describing fractures of condylar replacements, both cemented and uncemented. Predisposing factors include varus deformity either pre or post operatively. The mechanism of failure is thought to be failure of the infiltration of bone into the replacement. This is often due to polyethylene wear or metallosis causing abnormal tissue reaction with or without osteolysis. We present the case of a fractured Press Fit Condylar (PFC) cemented implant (DePuy, Johnson&Johnson, Raynham, Massachusettes, USA) affecting the medial condyle. To our knowledge this is only the third reported case of fracture in a PFC implant, and the first in a cemented PFC implant. Our patient was a 64 year old male who presented with unresolving knee pain post total knee arthroplasty, caused by fatigue fracture of the medial condyle of the femoral component. This was identified as loosening on plain radiographs and replaced with a revision prosthesis with a good post operative result. Given our aging population and with the increase of joint arthroplasty, this case sheds light on a potentially under recognised and increasingly important cause of knee pain following arthroplasty

Aims

Currently, there is no single, comprehensive national guideline for analgesic strategies for total joint replacement. We compared inpatient and outpatient opioid requirements following total hip arthroplasty (THA) versus total knee arthroplasty (TKA) in order to determine risk factors for increased inpatient and outpatient opioid requirements following total hip or knee arthroplasty.