The timing of definitive fixation for major fractures in polytrauma--a matched-pair comparison between a US and European level I centres: analysis of current fracture management practice in polytrauma.

PURPOSE: Early definitive stabilisation is usually the treatment of choice for major fractures in polytrauma patients. Modifications may be made when patients are in critical condition, or when associated injuries dictate the timing of surgery. The current study investigates whether the timing of fracture treatment is different in different trauma systems. MATERIALS AND METHODS: Consecutive patients treated a Level I trauma centre were documented (Group US) and a matched-pair group was gathered from the German Trauma Registry (Group GTR). INCLUSION CRITERIA: New Injury Severity Score (NISS)>16, >2 major fractures and >1 organ/soft tissue injury. The timing and type of surgery for major fractures was recorded, as were major complications. RESULTS: 114 patients were included, n=57 Group US (35.1% F, 64.9% M, mean age: 44.1 yrs±16.49, mean NISS: 27.4±8.65, mean ICU stay: 10±7.49) and n=57 Group GTR (36.8% F, 63.1% M, mean age: 41.2 yrs±15.35, mean NISS: 29.4±6.88, mean ICU stay: 15.6±18.25). 44 (57.1%) out of 77 fractures in Group US received primary definitive fracture fixation compared to 61 (65.5%) out of 93 fractures in Group GTR (n.s.). The average duration until definitive treatment was comparable in all major extremity fractures (pelvis: 5 days±2.8 Group US, 7.1 days±9.6 Group GTR (n.s.), femur: 7.9 days±8.3 Group US, 5.5 days±7.9 (n.s.), tibia: 6.2 days±5.6 Group US, 6.2 days±9.1 Group GTR (n.s.), humerus: 5 days±3.7 Group US, 6.6 days±6.1 Group GTR (n.s.), radius: 6 days±4.7 Group US, 6.1 days±8.7 Group GTR (n.s.). CONCLUSION: The current matched-pair analysis demonstrates that the timing of initial definitive fixation of major fractures is comparable between the US and Europe. Certain fractures are stabilised internally in a staged fashion regardless the trauma system, thus discounting previous apparent contradictions.

Postoperative analgesia with continuous sciatic nerve block after foot surgery: a prospective, randomized comparison between the popliteal and subgluteal approaches.

UNLABELLED: To compare the posterior popliteal and subgluteal continuous sciatic nerve block for anesthesia and acute postoperative pain management after foot surgery, 60 ASA physical status I and II patients undergoing elective orthopedic foot surgery were randomly assigned to either a Subgluteal group (n = 30) or Popliteal group (n = 30). Before surgery and after performing a femoral nerve block with 15 mL of 2% mepivacaine, we performed the sciatic nerve block with 20 mL of 0.75% ropivacaine using either a subgluteal or posterior popliteal approach, and the placement of a catheter came afterward. In the recovery room, the catheter was connected to a patient-controlled analgesia pump to infuse 0.2% ropivacaine (basal infusion rate of 5 mL/h, incremental bolus of 10 mL, and a lockout time of 60 min). There were no technical problems in catheter placement. Intraoperative efficacy of nerve block was similar in the two groups. Postoperative catheter displacement and occlusion were recorded in four patients in the Popliteal group and two patients in the Subgluteal group (P = 0.67). Both approaches provided similar postoperative analgesia. We conclude that the subgluteal approach is as effective and safe as the previously described posterior popliteal approach for continuous sciatic block and can be considered a useful alternative to anesthesia and acute postoperative analgesia after foot procedures. IMPLICATIONS: Comparing two different approaches for continuous sciatic nerve block after orthopedic foot surgery, this prospective, randomized study demonstrated that the subgluteal approach is as effective and safe as the previously described posterior popliteal approach, and can be considered a useful alternative to anesthesia and acute postoperative analgesia after foot procedures.