Intercondylar fibrotic lesion after retrograde intramedullary nailing of a femoral shaft fracture: a case report and review of the literature.

Retrograde intramedullary nailing is a largely successful technique for the treatment of femoral shaft fractures, although reports of knee pain after this procedure are not uncommon. Here we describe the case of a patient who developed a polyp-like fibrotic lesion of the intercondylar notch nearly 2 years after retrograde intramedullary nailing of a femoral shaft fracture as discovered by arthroscopic evaluation. This lesion caused pain and compromised our patient's function; however, both of these measures were subjectively improved after the debridement of the lesion. This case emphasizes the necessity of long-term follow-up and further investigation into the cause and significance of postoperative knee pain in hopes of continuing to improve patient outcomes.

Open wedge high tibial osteotomy: a roentgenographic comparison of a horizontal and an oblique osteotomy on patellar height and sagittal tibial slope.

BACKGROUND: In patients with unicompartmental medial knee arthritis, medial opening wedge high tibial osteotomy is used to shift the mechanical weightbearing line laterally to reduce pain and improve function. There have been concerns that opening wedge high tibial osteotomy is associated with a reduction of patellar height and increase in the sagittal posterior tibial slope, both of which can adversely affect the final result. HYPOTHESIS: A more distal oblique osteotomy at the level of insertion of the patellar tendon should decrease these effects when compared with a horizontal osteotomy made proximal to the patellar tendon insertion. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Review of 22 horizontal and 19 oblique high tibial osteotomies with a mean follow-up of 4.2 +/- 1.8 years (mean +/- SD) was performed. Anatomic tibiofemoral angle, mechanical weightbearing line, medial coronal tibial plateau angle, patellar height (Blackburne and Peel ratio), and sagittal tibial slope were measured. RESULTS: In both groups, the weightbearing line was equally shifted toward the center of the plateau. In the horizontal group, the Blackburne and Peel ratio decreased from 0.85 +/- 0.16 to 0.67 +/- 0.12, and the sagittal tibial slope was increased from 7.7 degrees +/- 4.6 degrees to 10.7 degrees +/- 3.8 degrees (P < .001). In comparison, the oblique group did not show any significant postoperative changes for these 2 parameters. In the oblique group, 2 patients sustained loss of correction and early failure when the osteotomy remained below the metaphyseal flare on the lateral cortex. CONCLUSION: The oblique osteotomy group showed more normalized postoperative sagittal tibial slope and patellar height. Caution should be exercised not to osteotomize too distally.

Chronobiological characteristics of postoperative pain: diurnal variation of both static and dynamic pain and effects of analgesic therapy.

BACKGROUND: Previous postoperative investigations report morning peaks in analgesic administration. However, few studies have examined diurnal variation of both pain and analgesic consumption and little is known about dynamic pain in this context. METHODS: The diurnal pattern of postoperative pain is described using pain intensity and analgesic consumption data from a recently published hysterectomy trial. RESULTS: In the presence of patient-controlled analgesia with morphine, pain at 8 a.m. was significantly higher (P<0.05) than at noon, 4 p.m. or 8 p.m. on postoperative day one (for rest pain and pain evoked by sitting, forced expiration and cough) and on postoperative day two (for pain evoked by forced expiration and cough only). This temporal pattern was observed both with and without the co-administration of non-opioid analgesics (gabapentin and/or rofecoxib). Morphine use during the four hours preceding 8 a.m. on either postoperative day was not significantly lower than any of the other corresponding time intervals. CONCLUSIONS: Based on data from our post-hysterectomy analgesic clinical trial, static and dynamic pain in the morning appears to be more intense than pain later in the day. This pattern was observed in the presence of substantial nocturnal morphine use. Based on these and other previous observations, specifically designed investigations are needed to better characterize the clinical, neurohormonal and neurophysiological features of postoperative circadian pain variation - including pain during sleeping hours. If the above observations are replicated, future study of nocturnal sustained-release opioids as well as time-shifting the administration of non-opioid co-analgesic drugs to the very early morning may be warranted.