Background. The degree of postoperative pain is usually moderate to severe following Total Hip Arthroplasty (THA). Comfort and lack of pain are important for optimal mobilization and earlier home discharge. Aim. To evaluate the efficacy and safety of Ropivacaine, a long- acting local anaesthetic, when infiltrated in the wound at the end of operation of THA. Methods. Seventy patients, 39 women and 31 men, ASA I-III, underwent Total Hip Arthroplasty in our clinic from January 2008 to June 2009. Patients were randomized into two groups. In group A, a solution of 100 ml Ropivacaine 2mg/ml (Naropeine 0,2%) was infiltrated in the deep tissues (capsule, gluteus medius, gluteus maximus and rotators) (50 ml) while the fascia, subcutaneous tissues and skin were infiltrated with the remaining 50ml. Group B was the control group. All patients received standardized general anesthesia or spinal anesthesia and a PCA morphine using a self-administered pain pump was applied in the recovery room for 48 hours. All patients took 1gr x 3 Apotel i.v., 40mg x2 Dynastat i.v., and 4mg x2 Zofron i.v. for 48 hours postoperative. Pain scores with Visual Analogue Scale (0–10) at 1, 2, 4, 8, 12, 24 and 48 hours postoperatively, time to the first analgesic requirement and side effects were recorded. Results. There were no significant differences in demographic characteristics of the patients and duration of the surgery between two groups. Morphine consumption was statistically significantly lower in group A for the first 48 hours, resulting in a lower frequency of nausea, itching and sedation. Postoperative pain levels at rest and during mobilization were statistically significantly lower in group A while median hospital stay was similar in both groups. Conclusion. Operative wound infiltration with ropivacaine reduces pain and the requirement for analgesics after hip replacement, leading to faster postoperative mobilization

Introduction. Chronic pain is one of the adverse outcomes in surgery for degenerative lumbar pathology (DLP). Postoperative complications as DVT, and chronic pain in pathologies as thoracotomy or breast cancer have been associated with poor control of postoperative pain. Study design. Prospective study of patients undergoing surgery for DLP. Purpose. To evaluate the relationship of postoperative pain with final outcomes in terms of chronic pain and quality of life. Outcome measures. Visual analogue scales (VAS) to assess lumbar and leg pain, Short Form-36v2 (SF-36), Oswestry Disability Index (ODI) and Core Outcome Measures Index (COMI). Method. 263 patients with a mean age of 54.0 years (22–86 y) were reviewed and 131 patients were women (49.8%). Pain, quality of life and disability of patients were assessed in the immediate preoperative and 2 years after surgery. Epidemiological data collected were age, sex, educational level, employment status, diagnosis, treatment, and comorbidity (ASA). An external nurse evaluated postoperative pain four times every day and we selected the worst value of day. The reference value of postoperative pain was the VAS of third day when patient starts standing and PCA is removed. To compare means we used t-Student and Pearson's coefficient or Spearman's test was used to assess the correlation, and, finally, linear regression study (ANOVA) was performed with variables that showed statistically significant correlation. SPSS 15.0 statistical package. Results. The mean value of VAS on 3rd day (VAS-3) was 2.86 ± 2.2. Postoperative pain showed a moderately positive correlation with final pain, measured by Bodily Pain (r=0.310, p <0.05) and final VAS (r=0.318, p <0.001), and moderately negative with the Physical Component Scale of the SF36 (r=−0.269, p <0.05). No significant correlations existed with the other instruments. Preoperative pain, sex and MSC-SF36 was correlated with postoperative pain (r=0.262 p <0.05; r=− 0.261 p <0.003, r=− 0.306 p <0.001). According to linear regression studies each point in the VAS-3 will be an increase of 0.522 points in the final VAS (p <0.01). Conclusions. Postoperative pain has moderate but statistically significant influence in the final lumbar pain perception, assessed by VAS and Bodily Pain. Postoperative pain has an inverse relationship to the physical component of SF-36. However, postoperative pain is not correlated with disability measured by ODI or COMI

Aims

For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

Aims

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets.

Aims

Surgery is often delayed in patients who sustain a hip fracture and are treated with a total hip arthroplasty (THA), in order to await appropriate surgical expertise. There are established links between delay and poorer outcomes in all patients with a hip fracture, but there is little information about the impact of delay in the less frail patients who undergo THA. The aim of this study was to investigate the influence of delayed surgery on outcomes in these patients.

Aims

The aim of this study was to investigate the association between additional rehabilitation at the weekend, and in-hospital mortality and complications in patients with hip fracture who underwent surgery.

Aims

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

Aims

Factors associated with high mortality rates in geriatric hip fracture patients are frequently unmodifiable. Time to surgery, however, might be a modifiable factor of interest to optimize clinical outcomes after hip fracture surgery. This study aims to determine the influence of postponement of surgery due to non-medical reasons on clinical outcomes in acute hip fracture surgery.

Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

Introduction. The treatment of trochanteric and subtrochanteric fractures remains controversial, and new implants are constantly being developed trying to improve outcome and minimize the number of complications in these fractures. In Norway the Sliding Hip Screw(SHS), with or without a Trochanteric Stabilizing Plate (TSP), is still the most commonly used implant, but worldwide nailing of these fractures is increasing. This trend, however, has not been supported by documentation of better clinical results compared to the SHS in well designed studies. Therefore, in the present study we compared the recently launched Trigen Intertan nail (Smith and Nephew) with the SHS in the treatment of trochanteric and subtrochanteric fractures. Patients and Methods. In a prospective, randomized multicenter study with 697 patients, we compared the Trigen Intertan nail with the SHS regarding postoperative pain, functional mobility, complications, and reoperation rates. Patients older than 60 years with trochanteric and subtrochanteric fractures were included in 5 hospitals. At day 5, and 3 and 12 months postoperatively, pain was measured using a Visual Analogue Scale (VAS), and the Timed Up and Go-test (TUG-test) was performed to evaluate functional mobility. Complications and reoperations were recorded at discharge, and after 3 and 12 months. Results. 328 patients were evaluated at day 5 postoperatively. At mobilization patients treated with the nail had less pain compared to the SHS (VAS 47 vs. 53, p=0.02). Still, a difference of 6 points may not be of clinical significance. There was no difference in pain at rest or in early functional mobility. The length of postoperative hospital stay was also similar for the two groups (8.5 and 8.4 days respectively). At 3 (457 patients) and 12 months (374 patients) there was no difference in pain or TUG-test performance. At discharge, and after 3 and 12 months the overall reoperation rate for the groups was similar, and there was no difference regarding general complications. The results were comparable for the two groups, regardless of fracture classification (stable or unstable fractures). However, postoperative femoral fractures still seems to be an issue even with modern nails. 5 postoperative femoral fractures were encountered in the Intertan group, whereas 1 occurred in the SHS-group. Conclusion. Overall, there was no major difference in the results for the Intertan nail and the SHS in our study. Both methods provided predictable and good results in the treatment of trochanteric and subtrochanteric fractures. We found however less pain at mobilization for patients operated with a nail at day 5 postoperatively compared to the SHS. No difference in pain or function was evident at any later follow up. There was no difference in reoperation rates between the groups, but more postoperative ipsilateral femoral fractures occurred in the Intertan group. The clinical results in this study do not support the trend towards more nailing of trochanteric and subtrochanteric fractures

At Bispebjerg University Hospital in Denmark, an Optimized Hip Fracture Program, (OHP) is the standard of care for all hip fracture patients. Part of OHP is pain treatment with a femoral nerve catheter placed at the emergency room, dosed 4 times a day with Bupivacain until 4 days after surgery, combined with systemic analgesics as needed. In 2008, a database and a bio bank were created at the ward including all hip fracture patients to make a better description of the population and as a tool for further optimisation of the OHP. One of the aims was to identify possible subgroups having specific complications, which could lead to a differentiation of the OHP by markers known at the time of admission. In this analysis, we will focus on postoperative pain that inhibits mobilization by fracture type and type of surgery. Methods. A consecutive cohort of 898 hip fracture patients hospitalized within two years from September 2008 to July 2010 was used for this study. Patients coming from nursing homes were excluded from the study, since nearly all are discharged 1 or 2 days after surgery to rehabilitation. If the exact type of fracture was not known, or if the patient was admitted for rehabilitation after surgery at another hospital, the patient was also excluded. 508 patients were thus included in the study. Mean age 80.0 years (SD:23.7), 72.1% women and 27.9% men. Mobilization inhibited by postoperative pain as documented in the patient files was registered in the database. Overall mobilization was inhibited by pain in 26.7% of the 508 patients included. The following fracture types were studied: Femoral neck Garden 1–2, Femoral neck Garden 3–4, Pertrochanteric Evans 1–2, Pertrochanteric Evans 3–5, Basocervical and Subtrochanteric. Results. Mobilization inhibited by pain was not significantly associated with type of surgery:. Cannulated Hip Screws 16/80 (20.0%), sliding hip screw 23/94 (24.5%), Intramedullary Nail 63/186 (33.9%), partial hip replacement 33/144 (22.9%), total hip replacement 1/5 (20.0%). P = 0.09 chi square. On the other hand mobilization inhibited by pain was significantly associated with fracture type:. Femoral neck Garden 1–2: 13/64 (20.3%), Femoral neck Garden 3–4: 38/172 (22.1%), Pertrochanteric Evans 1–2: 18/69 (26.1%), Pertrochanteric Evans 3–5: 46/149 (30.9%), Basocervical: 6/28 (21.4%), Subtrochanteric 15/27(55.6%). P = 0.009 chi square. Conclusion. The fracture types Pertrochanteric Evans 3–5 and Subtrochanteric had the biggest inhibition of mobilization caused by pain. No significant association between type of surgery and inhibition of mobilization caused by pain was found

Aims

To identify the prevalence of neuropathic pain after lower limb fracture surgery, assess associations with pain severity, quality of life and disability, and determine baseline predictors of chronic neuropathic pain at three and at six months post-injury.

Our study aims to demonstrate the efficacy of using endobutton and interference screw technique in the repair of acute distal biceps ruptures. From April 2009 to May 2013, 25 consecutive patients had acute distal biceps tendon repairs using an endobutton and interference screw technique. 3 patients were lost to follow up leaving 22 patients available for review. Mean follow up was 24 months(1–51). All were evaluated using a questionnaire, examination, radiographs, power measurements, and Oxford Elbow and MAYO scores. Overall 95% patients (21/22) felt that their surgery was successful and rated their overall experience as excellent or good. Mean return to work was at 100 days(0–280) and mean postoperative pain relief was 23 days(1–56). 55% returned to sport at their pre-injury level. There was one case (4.5%) of heterotopic calcification with 3 superficial infections(14%). There were no intra or postoperative radial fractures, metalwork failures or metalwork soft tissue irritations. Mean pre-operative Oxford Elbow Scores were 18(6–37) and post operative 43(24–48) (p<0.00001). Mean pre-operative Mayo scores were 48(5–95) and post-operative were 95(80–100)(p<0.00001). Our study supports that distal biceps repairs using the endobutton and interference screw technique appears to lead to high patient satisfaction rates with a relatively early return to function

Introduction. Although tension band wiring fixation of patellar fracture has been the most widely used technique, the metal implants related complications including implant loosening, postoperative pain are very common and additional surgeries are often necessary. Hypothesis. A totally metal free technique of transosseous suturing method could outperform the traditional fixation technique. Materials & Methods. A total of 25 patients (mean age of 59.60 years) with displaced patellar fracture treated by transosseous suturing technique were compared with a 1:1 matched historical control group who underwent modified tension band wiring fixation of patellar fracture. Union time, union rate, operation time, number of procedures, mean hospitalization days and the complications were compared between cases and controls. Results. Union time (8.43 ±2.92 weeks versus 8.64 ±2.82 weeks) and operation time (69.00 ±19.31 versus 64.89 ±14.27 minutes) were not different between two groups. Mean hospitalization days (4.04 ±1.40 versus 5.76 ±1.50 days; P < 0.001), number of procedures and the frequency of complications were significantly lower among transosseous suturing group (P< 0.001). Conclusions. Transosseous suturing technique is safe and effective in the transverse or comminuted fractures of patella. The complication rate is significantly lower than that of conventional tension band wiring technique

Patients undergoing total knee arthroplasty (TKA) experience significant postoperative pain. This impedes early mobilization and delays hospital discharge. A prospective audit of 1081 patients undergoing primary TKA during 2008 was completed. All patients followed a programme including preoperative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, postoperative high volume ropivacaine boluses with an intra-articular catheter and early mobilization. Primary outcome measure was length of stay. Secondary outcomes were verbal analogue pain scores on movement, time to mobilization, nausea and vomiting scores, urinary catheterization for retention, need for rescue analgesia, range of motion at discharge and six weeks postoperatively. The median day of discharge was postoperative day four. Median pain score on mobilization was three for first postoperative night, day one and two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterization rate was 6.9%. Rescue analgesia was required in 5% of cases. The median day of discharge was postoperative day four. Median range of motion was 85° on discharge and 93° at six weeks postoperatively. This comprehensive care plan provides satisfactory postoperative analgesia allowing early safe ambulation and discharge

Introduction. Depending on patient's age, risk factors and pretraumatic mobility, a total- or hemiarthroplasty of the hip have become the treatment of choice in femoral neck fractures(1–4). Internal fixation has shown to provide minor results. The majority of these patients are therefore treated by a hemiarthroplasty of the hip. Since the primary goal is to regain the pretraumatic level of mobility as soon as possible(3;5), we sought to investigate, if a minimal invasive anterior approach would be beneficial in regard of perioperative blood loss(6), postoperative pain(7;8) and thus postoperative mobility(9). Patients and methods. In a randomised controlled trial, 48 patients were treated by a hemiarthroplasty of the hip via an anterior or lateral approach in supine position within 72 hours after trauma(10). Apart from parameters like age, ASA-Score or Body-mass-index, the main focus was set on perioperative blood loss, pain and postoperative mobilisation. All data collected were compared between groups to detect statistical significant differences. Additionally the same parameters were checked for significant differences comparing patients with or without complications within their group. Results. A significant difference between groups was found for postoperative pain within the first 72 hours and for operation time, both to the disadvantage of the minimal invasive approach group. Within groups, time of operation and patient's age were significantly higher in patients with complications in the minimal invasive group such as pain at 48 hours was rated higher in patients with complications in the lateral approach group. These results though did not seem to influence postoperative mobility since no significant differences were found between groups at follow-up. Conclusion. Despite some differences in the postoperative course, postoperative mobility does not seem to be greatly influenced by the choice of the approach for hemiarthroplasty of the hip in femoral neck fractures. Still, the operation time was significantly linked to postoperative complications. In this respect, it can be concluded, that the approach an individual surgeon is most familiar with is likely to lead to best results

Background. Medial opening-wedge high tibial osteotomy is one of the common surgical procedures in treatment of knee deformities. Many methods have been proposed to fill the medial side osseous gap. The results of using allograft as void filler compared to iliac crest autograft has not been subject to a randomized clinical trial. The purpose of this study was to examine the results of medial opening-wedge high tibial osteotomy using iliac crest allograft as compared to iliac crest autograft. Materials & Methods. Forty-six patients with genovarum deformity were enrolled based on specific inclusion and exclusion criteria and were randomly assigned into two groups. Medial opening-wedge high tibial osteotomy was done using iliac crest allograft (23 patients) or autograft (23 patients) and the osteotomy site was internally fixed using proximal tibial T-plate. All patients were followed-up to 12 months after surgery. Anatomical indices of proximal tibia, complications of treatment, and functional outcome (using WOMAC osteoarthritis index) were assessed for both groups. Results. The amount of correction (degrees), recurrence of the deformity and loss of correction and time to clinical or radiologic union were similar in both groups with no statistically significant difference. Duration of operation was significantly less in allograft group (66.6±3.6 versus 52.9±5.3 minutes, p<0.001). Incidence of surgical site infection did not significantly differ in two groups. No nonunion or delayed union was encountered in either group. Some patients reported more intense postoperative pain in iliac graft harvest site than tibial osteotomy site. Patients in both groups had statistically significant improvement in WOMAC index postoperatively (with no statistically significant difference between groups). Conclusions. According to the results of this study, iliac crest allograft may be safely used in medial opening-wedge high tibial osteotomy with comparable efficacy to iliac crest autograft in patients who do not accept the morbidity of autograft harvest

Background. For some time, optimized perioperative pathway protocols have been implemented in orthopedic surgery. In our hospital an accelerated clinical pathway has been successfully in effect for several years, focused on safely decreasing patients' length of stay and increasing their function at the time of discharge. The aim of the present project was to evaluate whether a further optimization is even more promising regarding early postoperative outcome parameters. Materials and Methods. Prospective, parallel group design in an Orthopaedic University Medical Centre. 143 patients, scheduled for unilateral primary total knee replacement (TKR) under perioperative regional analgesia were included. 76 patients received a Standard Accelerated Clinical Pathway (SACP). 67 patients received an Optimized Accelerated Clinical Pathway (OACP) including patient-controlled regional analgesia pumps, ultra-early/doubled physiotherapy and motor driven continuous passive motion machine units. Main measures were early postoperative pain on a visual analogue scale, consumption of regional anaesthetics, knee range of motion, time out of bed, walking distance/stair climbing, circumference measurements and Knee Society Scores of the operated leg. Patients in both groups were checked for a possible discharge by a blinded orthopedic surgeon on the 5th and 8th postoperative (po) day, using a discharge checklist including the KATZ Index of Independence in Activities of Daily Living, standard requirements for pain at rest/mobilization, walking distance and regular wound healing. A potential discharge was only approved if the patient was able to meet all six criteria from the discharge checklist. Re-admission within 6 weeks after discharge from hospital was registered. Results. Patients within the OACP had significant benefits regarding stair climbing/walking distance/time-out-of bed/circumference measurements of the thigh/Knee Society function score on the 5th po day and stair climbing/circumference measurements of the thigh on the 8th po day, and reduction of the consumption of regional anaesthetics. No significant reduction in length of stay was observed. Discussion. Early postoperative functional process indicators tended to be higher within the OACP group, but the main effects flatten in the course of the first eight postoperative days. Further, prospective randomised clinical trials with uniform, objective discharge criteria are needed

A wide variety of intra- and extramedullary devices for the treatment of trochanteric fractures has been described. The Percutaneous Compression Plate is a minimally invasive and extramedullary device, which requires two 2–2.5 cm long incisions with minimal dissection oft soft tissue on the lateral aspect of the proximal femur. Earlier studies indicated that internal fixation using the PCCP is associated with a decreased perioperative blood loss, reduced transfusion requirements, with less postoperative pain, more rapid mobilisation, and with a reduced incidence of collapse of the fracture when compared with the standard device Dynamic Hip Screw. Aim of this study is to analyze the risk factors for the occurrence of local complications after internal fixation of intertrochanteric fractures of the femur using a Percutaneous Compression Plate. In a retrospective cohort study patients with trochanteric fractures who underwent internal fixation with a PCCP were included. We investigated the potential risk factors age, gender, experience of the surgeon as indicated by the numbers of surgical procedures with the PCCP device, stability of the fracture according to the AO/OTA classification, and co-morbidities of the patients according to the ASA classification. The operations were performed by ten different surgeons. All local complications which required re-operation were recorded. They included cutting out of the screw, loosening of the screw barrels, local haematoma, and infections. Logistic regression analysis was carried out to determine the risk factors for local complications. The mean age of the 122 patients included in this study was 78.5 years. 87 patients were female (70.7 %), 36 patients were male (29.3 %). With respect to the stability of the fracture 64 trochanteric fractures (52.5%) were classified as stable according to the AO/OTA classification, whereas 58 (47.5%) were considered to be unstable. Of the total of 122 patients with 122 trochanteric fractures eleven underwent re-operation due to local complications (9 %). The most frequent complication was complete or imminent cutting out of the upper cervical screw (N=5; 4 %). In the multivariate logistic regression model the only statistically significant risk factor was the experience of the surgeon (p=0.0316; odds ratio=4.7; CI 1.1–19.4). Our data indicate that the experience of the surgeon is a significant risk factor for the occurrence of local complications. The frequent use of this device seems to lower the re-operation rate

High volume infiltration with local anaesthetics (LIA) during total knee arthroplasty (TKA) for postoperative pain relief may be beneficial as compared to traditional methods. Retransfusion drains are used in TKA as alternative for allogeneic blood transfusions. When combining both modalities, recollected blood may contain large doses of local anaesthetics potentially leading to systemic toxicity during retransfusion. We investigated the safety of combining LIA and retransfusion of shed blood. Twenty patients scheduled for primary TKA were included. During surgery two peri-articular injections with ropivacaine (total 375 mg) were given. Patients received an intraarticular retransfusion drain and a wound catheter for continuous infusion of ropivacaine (8 mg/hr) for 24 hours. Blood collected in the retransfusion device, was not retransfused but used for laboratory analyses. Patients’ blood samples were taken immediately after surgery, 3, 6 and 24 hours postoperatively. We predicted cumulative ropivacaine concentrations using patient and shed blood samples from 6 hours postoperatively. We modelled instant retransfusion by estimating the cumulative plasma concentrations. Our safety threshold was 0.15 mg/L unbound ropivacaine in a venous plasma sample, based on literature. Total ropivacaine concentration was highest 24 hours postoperatively and unbound ropivacaine was maximal predominantly at 6 hours. Total ropivacaine concentrations ranged from 0.7 to 1.9 mg/L and unbound ropivacaine concentrations varied between 0.03 and 0.11 mg/L. At 6 hours median shed blood volume was 600 mL (range 303–869 mL). Interestingly was the difference (mean ± SD) in free fraction ropivacaine, in shed blood (68.8–4.6%) and in plasma (4.8 ± 1.1%). Assuming retransfusion, an average 13 mg (range 6–18mg) of unbound ropivacaine would have been administered intravenously. The model used to estimate cumulative ropivacaine plasma levels showed that instant retransfusion potentially would have led to unbound venous plasma concentrations of above 0.15 mg/L. Under the conditions in our study it is safe to use LIA in combination with continuous infusion of ropivacaine. However, in combination with the retransfusion of shed blood collected with the Bellovac ABT system this may lead to toxic levels. Before implementing the combination of both modalities formal testing is required