The Role of Perioperative Nutritional Status and Supplementation in Orthopaedic Surgery: A Review of Postoperative Outcomes.

¼ Identification of malnourished and at-risk patients should be a standardized part of the preoperative evaluation process for every patient.¼ Malnourishment is defined as a disorder of energy, protein, and nutrients based on the presence of insufficient energy intake, weight loss, muscle atrophy, loss of subcutaneous fat, localized or generalized fluid accumulation, or diminished functional status.¼ Malnutrition has been associated with worse outcomes postoperatively across a variety of orthopaedic procedures because malnourished patients do not have a robust metabolic reserve available for recovery after surgery.¼ Screening assessment and basic laboratory studies may indicate patients' nutritional risk; however, laboratory values are often not specific for malnutrition, necessitating the use of prognostic screening tools.¼ Nutrition consultation and perioperative supplementation with amino acids and micronutrients are 2 readily available interventions that orthopaedic surgeons can select for malnourished patients.

Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis.

PURPOSE: Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis. METHODS: This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis. RESULTS: 2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025). CONCLUSION: WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures. REGISTRATION: PROSPERO: CRD42023404018.

The Role of Amino Acid Supplementation in Orthopaedic Surgery.

The nutritional status of patients undergoing orthopaedic surgery has started to garner increasing attention in published literature. Notable previous evidence has demonstrated the negative effect of malnutrition on outcomes after orthopaedic procedures. Although there has been increased recognition of malnutrition as a risk factor for suboptimal outcomes, the use of nutritional supplementation to mitigate those risks is not well understood. The purpose of this review of most current literature on the topic is to introduce and elucidate the role of amino acid supplementation as a countermeasure to muscle loss and improvement of nutritional status in orthopaedic patients to improve results and outcomes after orthopaedic surgery.

Percutaneous release for trigger thumb in children under local anesthesia.

Trigger thumb surgery can be performed through open surgery or percutaneous release. Open surgery often requires hospitalization, an operating room, a surgical incision, and postoperative wound care; however, percutaneous release does not require hospitalization or surgery, and is relatively easier and faster. We aimed to assess the results of percutaneous A-1 pulley release using local anesthesia without hospitalization for the treatment of pediatric trigger thumb. In this retrospective study, we included patients operated on between March 2013 and August 2020 with the diagnosis of trigger thumb. The percutaneous release under local anesthesia was applied to all the children by one orthopedic surgeon. All percutaneous release procedures were performed in outpatient clinic conditions. There were 183 children (218 thumbs) who were enrolled in the clinic. Eighty-seven patients were male (47.5%) and 96 were female (52.5%). The average follow-up duration was 5 years (1-8.5 years). Among the 218 trigger thumb cases, 211 were satisfactory (successful result rate 96.8%). Relapse was seen in only 3 thumbs in the early postoperative period. No patient experienced neurovascular deficit or infection. The percutaneous surgical release in pediatric trigger thumb treatment is a simple, minimally invasive procedure that can be done in an outpatient setting under local anesthesia. In addition, the procedure duration is short and has minimal complication rates and maximum patient satisfaction. Level of Evidence III.

A not so sweet scenario: impact of perioperative glucose control on regional anesthetic techniques for orthopedic surgery.

PURPOSE OF REVIEW: Diabetes and hyperglycemia are well established risk factors for complications associated with common orthopedic surgeries. In some practice settings, these conditions are also viewed as contraindications to regional nerve catheters. In this article, we aim to present our approach to offering the benefits of this modality in a safe manner for patients with diabetes and even some with preexisting, localized infections. RECENT FINDINGS: Evidence suggests that reduction in opioids and avoidance of general anesthesia can be particularly beneficial for patients with diabetes and high blood sugar, who often suffer from comorbid conditions such as obesity and obstructive sleep apnea. On our high volume, high acuity acute pain service, we take a selective approach to nerve catheter placement in this population and even some who already have localized infections. In our experience, with careful monitoring and risk mitigation strategies these patients have improved pain control and an exceedingly low rate of complications associated with nerve catheter use. SUMMARY: Based on our experience and reading of the literature, we advocate for a liberalized approach to use of continuous regional anesthesia for diabetic patients having for orthopedic surgery. A set of consensus guidelines tailored to institutions' resources and monitoring capabilities can be a useful tool for standardizing care. It may also increase access to the clinical benefits of this modality in a population particularly vulnerable to opioid related adverse effects.

Safety of Influenza Vaccination During Orthopaedic Surgery Hospitalizations.

BACKGROUND: Despite national recommendations, influenza vaccination rates during hospitalizations remain low. Inpatient hospitalization for orthopaedic surgery remains a largely missed opportunity for vaccination. To address potential concerns regarding safety, we evaluated whether influenza vaccination during hospitalization for orthopaedic surgery increases evaluations for infection postdischarge because patients and clinicians often cite fear of this potential outcome. METHODS: This was a retrospective cohort study that was conducted among patients of a large integrated healthcare organization aged ≥6 months who were hospitalized for an orthopaedic surgery (defined by International Classification of Diseases, Ninth Revision procedure codes) between September 1 and March 31 from 2011 to 2014. Using propensity score matching (1:1) to adjust for confounding, we assessed the association between influenza vaccination during an inpatient stay for orthopaedic surgery and rates of readmission, emergency department visits, outpatient visits, fever (temperature ≥38.0°C), and evaluations for infections less than 7 days postdischarge. RESULTS: Overall, 2,395 hospitalizations with inpatient vaccination and 21,708 hospitalizations without inpatient vaccination were identified. Following successful balance of covariates (standardized difference <0.1 for all covariates) through 1:1 propensity score matching, we included 2,376 exposed patients and 2,376 unexposed patients in the matched analysis. In adjusted analyses, compared with those who were not vaccinated during hospitalization, those vaccinated during an inpatient stay for orthopaedic surgery had no statistically significant increase in readmission (relative risk [RR] = 1.00, 95% confidence interval [CI]: 0.75 to 1.34), emergency department visits (RR = 1.14, 95% CI: 0.93 to 1.41), fever (RR = 1.31, 95% CI: 0.81 to 2.12), or clinical workups for infection (RR = 1.08, 95% CI: 0.98 to 1.18). A marginally increased risk of outpatient visits in the 7 days postdischarge was detected (RR = 1.13, 95% CI: 1.02 to 1.26). DISCUSSION: There was no evidence of a substantial increased risk of infection-related outcomes associated with influenza vaccination during hospitalization for orthopaedic surgery. Our data support the recommendation of vaccinating orthopaedic surgery patients against influenza perioperatively.

Effect of non-pharmacological interventions on anxiety, depression, sleep quality, and pain after orthopedic surgery: A protocol for systematic review and network meta-analysis.

BACKGROUND: Patients after orthopedic surgery often experience the pain, anxiety, depression, and sleep disturbances, which can be greatly reduced by non-pharmacologic interventions as alternative therapies. Randomized controlled trials of nonpharmacologic interventions for anxiety, depression, sleep quality, and pain in patients after orthopedic surgery have been reported, but the results may be conflicting. Evidence to determine the optimal non-pharmacological intervention with a high efficacy is limited. This study aims to assess the effects of non-pharmacologic interventions on the bone anxiety, depression, sleep quality, and pain in patients after orthopedic surgery through a network meta-analysis, thus providing guidance in clinical application. METHODS: A systematic search of randomized controlled trials reporting the effects of non-pharmacological interventions on anxiety, depression, sleep quality and pain after orthopedic surgery published before October 2021 will be searched in Wanfang, VIP Information Chinese Journal Service Platform, China National Knowledge Infrastructure, Chinese BioMedicine Literature Database, Pubmed, Embase, Cochrane, and Web of science. Two reviewers will be independently responsible for study selection, quality appraisal, and data extraction. Stata 14.0 software will be used to perform the network meta-analysis. RESULTS: The findings of this research will be reported in a recognized journal. CONCLUSION: This meta-analysis will provide the stronger evidence for non-pharmacological interventions on alleviating bone anxiety, depression, sleep quality, and pain in patients after orthopedic surgery, which will help clinicians and decision makers in their choices.Open Science Framework registration number: DOI 10.17605/OSF.IO/2SCBD.

Music Intervention to Orthopedic Patients: A Possible Alternative Solution to Control Pain.

Aims and Objective. Pain is a common problem associated with postoperative orthopedic patients; the current study is aimed at evaluating music intervention as an alternative method to control pain. Methodology. The experimental design of the current study was comparative, descriptive, and quasi-experimental. 38 postoperative orthopedic patients were equipped with pocket-size MP3 players with prerecorded music tracks (instrumental and lyrical) in Hindi, English, and Urdu. After that, pre-post-pain scores were recorded with the help of designed brief patient logs. Ultimately, a satisfactory survey was completed at discharge. Major Findings. It was found that during the intervention of music, the pain was significantly reduced from 5.40 to 2.98. There was a slight relationship between listening time and pain relief. It was also found that the feedback was extremely positive and each patient suggested the use of music to others with 96.6% recommendation. Conclusion. From the current study, it was found that music intervention can be beneficial to postoperative patient pain control. Further, it is hoped that the findings of the current experimental work will lead to improvements in the care of postoperative patients.

WALANT Hand Surgery Does Not Require Postoperative Opioid Pain Management.

BACKGROUND: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Factors Predicting Chronic Opioid Use after Orthopedic Surgical Procedures.

BACKGROUND: Opioid abuse has been an increasing problem since the 1990s. With over 47,000 opioid related deaths recorded in 2017 alone, concerns have been raised regarding the dangers of introducing opioids perioperatively to patients undergoing major surgeries. OBJECTIVES: The present study proposes to examine the frequency, amount, and trends in post-operative opioid consumption in patients undergoing orthopedic surgical procedures. STUDY DESIGN: This was a randomized, retrospective questionnaire-based study. SETTING: Patients who underwent any type of orthopedic surgery at the University of Pennsylvania Presbyterian Hospital from 1/1/2018 to 3/12/2019 were randomly selected and called during the summer of 2019. METHODS: In this retrospective questionnaire-based study, 828 patients were called by telephone in the summer of 2019. These patients were asked a variety of questions involving opioid consumption behavior post-surgery. The study ended after receiving responses from 200 patients. RESULTS: Nineteen (9.5%) patients reported positively for experiencing euphoria while taking opioids post-surgery. Of the 200 patients contacted, 6 patients (3%) reported switching to marijuana instead of opioids. Thirty-eight (19%) patients preferred to take no opioids at all post-surgery, and one patient was found to have given their prescription to a family member or friend. Twenty-one patients (10.5%) were found to have been taking opioids for non-severe pain. Blacks and whites were the most common racial demographics, making up 84 and 109 of the totals, respectively. The odds ratios for all of the predictors showed that the relative risk for opioid misuse was higher for black patients than white patients (OR = 3.034). There was no relationship between the intra- and post-operative opioid administration and long-term opioid misuse. LIMITATIONS: Patients are self-selected and had the option to opt out of the study when contacted. Some patients may not have been available to answer the phone when our study was being conducted. This study was only conducted for orthopedic patients and for patients who received surgery at the University of Pennsylvania Presbyterian Hospital, thus affecting the demographics for our research. CONCLUSIONS: Prescription opioid misuse is more common among the black population. The total opioid consumption is frequently lower than the quantity prescribed. Patients frequently use opioids even though they feel that pain is insufficient to deserve such an intervention. Euphoria is experienced by a significant number of patients taking prescription opioids Often patients do not take any opioids, although they had prescriptions.

The Physiological Effects, Including Risks and Potential Benefits, of Cannabis for Patients Undergoing Elective Orthopedic Procedures.

Given the evolving regulations regarding and availability of cannabis in the United States, physicians should understand the risks and benefits associated with its use. Patients are interested in learning about the use of cannabis for the management of orthopedic pain and any potential risks associated with it when undergoing elective surgery. Edible and topical cannabis products appear to have fewer side effects than inhaled cannabis products. A review of the literature was performed regarding different modes of administration and their related risks and potential benefits specifically regarding perioperative concerns for elective orthopedic procedures. Larger studies are necessary to further determine the efficacy, safety, and side effect profile of cannabis. [Orthopedics. 2021;44(3):e314-e319.].

Rationale for Bone Health Optimization in Patients Undergoing Orthopaedic Surgery.

Osteoporosis is common, affecting more than 40 million people, and is associated with increased fracture risk, loss of independence, chronic pain, and disability. Osteoporosis is underdiagnosed and undertreated even after fracture where secondary fracture prevention has been shown to be cost effective in reducing further fracture risk and mortality. Osteoporosis is also undiagnosed in patients undergoing orthopaedic and spine surgery in up to one-third of cases and negatively affects outcomes, need for revision surgery, and risk of complications. The diagnosis of osteoporosis was previously based on bone mineral density; however, recent clinical definitions include T-scores less than -2.5, the presence of hip and spine fractures, and high fracture risk. Surgeons should adopt bone health optimization for elective surgery. This program screens patients to determine whether a bone mineral density test is indicated and provides counseling for nutritional supplements, elimination of toxins, fall risk assessment, and education regarding bone health. Following assessment, patients meeting the criteria for osteoporosis are referred to a bone health specialist or a fracture liaison program. Both antiresorptive and anabolic antiosteoporotic medications appear effective at improving outcomes and reducing complications of orthopaedic and spine surgery, although a delay in surgery may be required.

Malnutrition in Orthopaedic Sports Medicine: A Review of the Current Literature.

CONTEXT: Malnutrition is well-studied in various aspects of the orthopaedic literature, most commonly in relation to arthroplasty, spine surgery, and trauma. However, the management of nutritional deficiencies is commonly overlooked among orthopaedic sports medicine providers. The purpose of this article is to analyze the available sports medicine literature to review the associations between malnutrition and the management of orthopaedic sports medicine patients from a treatment and performance standpoint. EVIDENCE ACQUISITION: PubMed was searched for relevant articles published from 1979 to 2019. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 4. RESULTS: Few studies exist on the implications of macronutrient deficiencies specific to orthopaedic sports medicine procedures. Interestingly, micronutrient disorders-namely, hypovitaminosis D and iron deficiency-have been well studied and may lead to worse postoperative outcomes, injury rates, and athletic performance. Nutritional supplementation to correct such deficiencies has been shown to mitigate these effects, though further study is required. CONCLUSION: Nutritional deficiencies are highly prevalent in orthopaedic sports medicine patients, and practitioners should be aware of their potential effects on treatment and performance outcomes. Management of such deficiencies and their effect on surgical patients remain an area of potential future research. Future studies are warranted in order to explore the potential therapeutic role of nutritional supplementation to prevent complications after common orthopaedic sports medicine procedures, improve athletic performance, and reduce injury rates.

Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective?

BACKGROUND: Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference. QUESTIONS/PURPOSES: To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data. METHODS: A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty. RESULTS: The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective. CONCLUSIONS: Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Effect of Music Therapy on Pain After Orthopedic Surgery-A Systematic Review and Meta-Analysis.

BACKGROUND: Although music interventions on postoperative pain (POP) have positive effects, limited research has focused on systematic reviews and meta-analyses of its efficacy for orthopedic patients. This systematic review aimed to examine the effects of music therapy on pain after orthopedic surgery. METHOD: The Cochrane Library, PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Nursing Reference Center (NRC), Airiti Library, and National Digital Library of Theses and Dissertations in Taiwan were searched up to August 2019. The risk of bias from the Cochrane Handbook for Randomized Controlled Trials of Interventions was used. A standard mean difference (SMD) with 95% confidence intervals (CIs) was applied as a summary effect on postoperative pain and anxiety using RevMan version 5.3. A meta-analysis was also carried out using subgroup analysis. RESULTS: Nine randomized controlled trials were selected. (1) Music can relieve pain significantly for both music medicine (MM; SMD = -0.41, 95% CI [-0.75, -0.07], P = 0.02) and music therapy (MT; SMD = -0.31, 95% CI [-0.57, 0.04], P = 0.02). (2) Music chosen by the subjects showed significant differences for both MM (P = 0.002) and MT (P = 0.02). (3) Anxiety improved significantly among patients using MT (SMD = 0.44, 95% CI [-0.75, -0.13], P = 0.005). However, the results for the physiologic parameters, opioid requirement, and length of stay showed subtle distinctions. CONCLUSION: Music can significantly relieve POP, specifically music chosen by the participants.

Incidence of Thromboembolic Events in Oncology Patients Receiving Intraoperative Tranexamic Acid During Orthopedic Surgery: A Retrospective Review at a Comprehensive Cancer Center.

Despite an abundance of evidence, routine perioperative antifibrinolytics have been avoided in oncology patients due to concern of thrombosis when given to patients with a preexisting hypercoagulable state. We present a retrospective review of 104 patients with an oncologic diagnosis who received intraoperative tranexamic acid during orthopedic surgery. Overall, complication rates were low, including deep vein thrombosis (1.0%), pulmonary embolism (4.8%), stroke (0%), and myocardial infarction (0%). This preliminary evidence shows that antifibrinolytics such as tranexamic acid may be considered perioperatively in oncology patients without increased risk of thromboembolic events; however, further prospective trials are encouraged.

Cannabis for pain in orthopedics: a systematic review focusing on study methodology

Background: Medical cannabis use is an emerging topic of interest in orthopedics. Although there is a large amount of literature on medical cannabis use for managing various types of pain, few studies have focused on orthopedic conditions. There is little high-quality evidence in core orthopedic areas. The objective of this study was to summarize the literature on the efficacy of cannabis use for pain related to orthopedic conditions. Methods: We conducted a systematic review of the literature on the use of cannabinoids for pain management in core orthopedic conditions. Two independent reviewers extracted information on reporting quality, risk of bias, drugs, population, control, duration of study, pain outcomes and the authors' conclusions regarding efficacy for pain outcomes. Results: We identified 33 orthopedic studies, including 21 primary studies and 12 reviews. Study quality was generally low to moderate. Six of the included studies had a control group and 15 were noncontrolled studies. Methodologies, drugs and protocols of administration varied greatly across studies. Study conclusions were generally positive in noncontrolled studies and mixed in controlled studies. Studies using higher doses tended to conclude that cannabis use was effective, but the potential for harmful effects may also be increased with higher doses. Conclusion: Variability in the methodologies used in cannabis research makes it challenging to draw conclusions about dosing, routes and frequency of administration. Most of the existing evidence suggests that medical cannabis use is effective, but this efficacy has been demonstrated only when either there is no comparator or cannabis is compared with placebo. Studies using an active comparator have not demonstrated efficacy. Future research should focus on improving study reporting and methodologic quality so that protocols that optimize pain control while minimizing harmful effects can be determined.

Contexte: La consommation de cannabis à des fins médicales est un sujet d'intérêt émergent en orthopédie. Malgré l'existence d'un important corpus de littérature médicale sur l'utilisation du cannabis pour traiter divers types de douleurs, peu d'études ont porté sur les problèmes orthopédiques. On dispose de peu de données probantes de grande qualité relatives aux principaux domaines de l'orthopédie. L'objectif de cette étude était de résumer la littérature sur l'efficacité du cannabis à soulager les douleurs orthopédiques. Méthodes: Nous avons réalisé une revue systématique de la littérature sur l'utilisation des cannabinoïdes pour la prise en charge de la douleur associée aux principaux problèmes orthopédiques. Deux examinateurs indépendants ont extrait l'information sur la qualité des rapports, le risque de biais, les médicaments, les populations et groupes témoins, la durée des études, les scores de douleur et les conclusions des auteurs quant à l'efficacité au plan des scores de douleur. Résultats: Nous avons recensé 33 études orthopédiques, dont 21 études primaires et 12 revues. La qualité des études était généralement de faible à moyenne. Six des études incluses étaient contrôlées et 15 ne l'étaient pas. Les méthodologies, les médicaments et les protocoles d'administration variaient grandement d'une étude à l'autre. Les conclusions étaient généralement positives dans les études non contrôlées, et mixtes dans les études contrôlées. Les études qui utilisaient des doses plus fortes avaient tendance à conclure que le cannabis était efficace, mais le risque d'effets négatifs pouvait également être proportionnel à la dose. Conclusion: En raison de la variabilité des méthodologies utilisées dans la recherche sur le cannabis, il est difficile de tirer des conclusions sur la posologie, les voies et la fréquence d'administration. La plupart des preuves disponibles donnent à penser que le cannabis médical est efficace, mais cette efficacité n'a été démontrée que s'il n'y avait pas de comparateur ou si le cannabis était comparé à un placebo. Les études ayant utilisé un comparateur actif n'ont pas fait état d'efficacité. La recherche future devrait veiller à améliorer les rapports et la qualité méthodologique des études afin de déterminer quels protocoles améliorent la maîtrise de la douleur tout en réduisant les effets négatifs.

Neurogenic hallux valgus. A rare complication of spinal surgery.

INTRODUCTION: Post-surgical lumbar spine syndrome is the result of failed or unsuccessful back surgery. It is defined as failure to relieve pain and disability in the lower back and extremities following surgery. This case report suggests inclusion of neurogenic hallux valgus to the list of potential complications following failed lumbar spine surgery. CASE REPORT: A severe unilateral hallux valgus deformity with an irreducible dislocation of the metatarsophalangeal joint due to complete wasting of the abductor hallucis muscle was diagnosed in a 73-year-old woman admitted for a hip fracture. The patient reported that the deformity developed after a failed lumbar spine surgery, which included decompression and stabilization of L2-S1 with posterior instrumentation 6 years previously. The deformity progressively deteriorated over a 3-year-period. Three months following the hip fracture surgery, the patient went through a neurological examination and an electrophysiological study. The findings indicated that the left hallux valgus deformity most likely developed because of the abductor hallucis muscle wasting due to S1 nerve root injury secondary to the failed lumbar spine surgery. CONCLUSION: Post-surgical lumbar spine syndrome may be a reasonable causative etiology of a severe unilateral hallux valgus deformity with an irreducible dislocation of the metatarsophalangeal joint due to complete wasting of the abductor hallucis muscle secondary to S1 nerve root injury.

Sonotherapy in the reduction of anxiety and postoperative pain in patients with regional anesthesia as a sole technique: randomized, controlled clinical trial.

OBJECTIVE: To determine if sonotherapy reduces the anxiety level and postoperative pain in adults undergoing outpatient orthopedic surgery under regional anesthesia. METHOD: A randomized, double-blind, placebo-controlled study in 80 adult patients undergoing orthopedic surgery, 40 received intervention with sonotherapy and 40 did not receive it. Pain, anxiety in the preoperative period, immediate postoperative, high, 24 and 48 hours later were measured. Hemodynamic parameters were measured in four moments. RESULTS: No significant differences were found between the two groups in the pain scales neither anxiety. A significant reduction of the systolic blood pressure was observed after the application of sonotherapy and in recovery. There was no difference in other hemodynamic variables such as heart rate, respiratory rate, arterial oxygen saturation or diastolic blood pressure between groups, however, the observed changes in some of them occurred faster in the intervention group. CONCLUSIONS: In adult patients undergoing outpatient orthopaedic surgery under regional anaesthesia, sound therapy is a novel strategy that significantly reduces systolic blood pressure, considered as an indicator of decreased anxiety. However, in our study, no difference could be demonstrated in terms of pain control or the need for additional sedation or analgesia.

OBJETIVO: Evaluar la eficacia de la sonoterapia en la diminución de la ansiedad y el dolor posoperatorio en adultos llevados a cirugía ambulatoria de ortopedia bajo anestesia regional. MÉTODO: estudio aleatorizado, doble ciego, controlado con placebo, en 80 pacientes adultos sometidos a cirugía ortopédica; 40 recibieron intervención con sonoterapia y 40 no la recibieron. Se midieron el dolor y la ansiedad en el preoperatorio, en el posoperatorio inmediato, al alta, y 24 y 48 horas después. Se midieron parámetros hemodinámicos en cuatro momentos. RESULTADOS: No se encontraron diferencias significativas entre ambos grupos en las escalas de dolor ni ansiedad. Se observó una reducción significativa de la presión arterial sistólica luego de la aplicación de la intervención y en recuperación. No se observaron diferencias en otras variables hemodinámicas entre los grupos, pero la reducción de algunas ocurre de forma más rápida en el grupo de intervención. CONCLUSIONES: En pacientes adultos llevados a cirugía ambulatoria de ortopedia bajo anestesia regional, la sonoterapia es una estrategia novedosa que reduce la presión arterial sistólica, y esto puede considerarse como un indicador de disminución de la ansiedad. En nuestro estudio no se pudo demostrar diferencia en términos de control del dolor ni de requerimiento de sedación o analgesia adicional.

Effectiveness of electrical stimulation for postoperative pain in patients with osteosarcoma: A systematic review protocol of clinical controlled trial.

BACKGROUND: This study aims to investigate the effectiveness and safety of electrical stimulation (ES) for postoperative pain (PPP) in patients with osteosarcoma systematically. METHODS: We will systematically search the following electronic databases from inception to the May 1, 2019: MEDILINE, Cochrane Library, EMBASE, Web of Science, Springer, and CNKI without language restrictions. All literatures of randomized controlled trials (RCTs) and case-controlled studies (CCSs) of ES for PPP in patients with osteosarcoma will be included. RevMan 5.3 software (Cochrane Community; London, UK) and STATA 15.0 software (StataCorp; College Station) will be used for statistical analysis. Cochrane risk of bias will be used for methodological quality assessment for RCTs and Newcastle-Ottawa Scale will be utilized for CCSs. RESULTS: This study will assess the clinical effectiveness and safety of ES for PPP in patients with osteosarcoma through assessing primary outcome of pain intensity and secondary outcomes of frequency of rescue analgesic use, cumulative morphine consumption, quality of recovery, as well as adverse events. CONCLUSION: This study will provide latest evidence on effectiveness and safety of ES for PPP in patients with osteosarcoma, and may also provide guidance for both clinician and further studies. DISSEMINATION AND ETHICS: This study does not require ethical approval, because it will not analyze the individual patient data. Its results are expected to be published in peer-reviewed journals. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019135790.