Multimodal analgesia practices for knee and hip arthroplasties in the Netherlands. A prospective observational study from the PAIN OUT registry.

INTRODUCTION: Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes. METHODS: Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea. RESULTS: In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3). CONCLUSION: In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.

Esophageal rupture in a child after vertical expandable prosthetic titanium rib expansion thoracoplasty: first report of a rare complication.

STUDY DESIGN: Case report and clinical discussion. OBJECTIVE: To illustrate the significance of esophageal rupture as a rare complication after expansion thoracoplasty with implementation of a vertical expandable prosthetic titanium rib (VEPTR). SUMMARY OF BACKGROUND DATA: Chest wall deformities and secondary scoliosis are rare complications after a repair operation for esophageal atresia. The new technique of VEPTR expansion thoracoplasty directly treats the chest wall deformity and indirectly corrects the scoliosis. We describe a patient with an esophageal rupture after VEPTR expansion thoracoplasty. METHODS: We report the case of an 11-year-old boy who developed a progressive scoliosis caused by fused ribs after multiple reoperations for esophageal atresia. The patient was treated operatively by an expansion thoracoplasty via an opening wedge thoracostomy with implementation of two VEPTRs. RESULTS: After surgery, the patient developed a respiratory insufficiency because of rupture of the esophagus. The complication was treated conservatively. A second operation was needed to remove an infected VEPTR. The patient fully recovered after this severe complication. CONCLUSION: To our knowledge, this is the first report of esophageal rupture after VEPTR expansion thoracoplasty. This promising new technique treats scoliosis in patients with severe chest wall deformities. When a patient presents with fused ribs and there is a history of esophageal atresia, we should keep in mind that the esophagus is at risk of rupturing during the scoliosis correcting procedure.