Continuous wound infusion and local infiltration analgesia for postoperative pain and rehabilitation after total hip arthroplasty.

BACKGROUND: Total hip arthroplasty is one of the most common procedures in orthopedic surgery. We hypothesized that local infiltration of analgesia and continuous wound infusion of anesthetics in the first 72 hours after surgery could provide more effective postoperative analgesia with better rehabilitation. METHODS: A double-blind, randomized, controlled study was conducted with 96 patients who underwent total hip arthroplasty. The patients were randomized to receive either a local infiltration analgesia and continuous wound infusion of anesthetics or a local infiltration analgesia and continuous wound infusion of saline solution. The patients in both groups received subarachnoid anesthesia and a local infiltration analgesia. A multihole catheter was placed next to the implant and connected to an electronic pump containing a 300-mL solution of 0.2% levobupivacaine (experimental group) or saline (control group). RESULTS: A total of 96 consecutive patients were enrolled and randomized. Of these, 48 patients received local infiltration analgesia and continuous wound infusion of local anesthetics, and the remainder received local infiltration analgesia and continuous wound infusion of saline solution. The analysis showed a significant main effect of treatment on the postoperative incident of pain (Ftreat(1,93)=22.62, P=0.000) and on resting pain during the post-surgery follow-up (Ftreat(1,93)=15.62, P=0.0002). The pain scores during the rehabilitation period were significantly less in the experimental group. Analgesic consumption was less in the experimental group. CONCLUSIONS: The addition of continuous wound infusion of anesthetics to local infiltration analgesia provided an extended analgesic effect associated with good rehabilitation performance.

A computer-assisted navigation technique to perform bone tumor resection without dedicated software.

PURPOSE: In oncological orthopedics, navigation systems are limited to use in specialized centers, because specific, expensive, software is necessary. To resolve this problem, we present a technique using general spine navigation software to resect tumors located in different segments. MATERIALS AND METHODS: This technique requires a primary surgery during which screws are inserted in the segment where the bone tumor is; next, a CT scan of the entire segment is used as a guide in a second surgery where a resection is performed under navigation control. We applied this technique in four selected cases. To evaluate the procedure, we considered resolution obtained, quality of the margin and its control. RESULTS: In all cases, 1 mm resolution was obtained; navigation allowed perfect control of the osteotomies, reaching the minimum wide margin when desired. No complications were reported and all patients were free of disease at follow-up (average 25.5 months). CONCLUSIONS: This technique allows any bone segment to be recognized by the navigation system thanks to the introduction of screws as landmarks. The minimum number of screws required is four, but the higher the number of screws, the greater the accuracy and resolution. In our experience, five landmarks, placed distant from one another, is a good compromise. Possible disadvantages include the necessity to perform two surgeries and the need of a major surgical exposure; nevertheless, in our opinion, the advantages of better margin control justify the application of this technique in centers where an intraoperative CT scanner, synchronized with a navigation system or a dedicated software for bone tumor removal were not available.

Hemostatic matrix effects on blood loss after total knee arthroplasty: A randomized controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) can result in major postoperative blood loss which can impact on the recovery and rehabilitation of patients. It also requires expensive transfusions. The purpose of the study was to investigate whether a hemostatic matrix, composed of cross-linked gelatin and a thrombin solution, would reduce blood loss in patients following TKA. MATERIALS AND METHODS: THIS WAS A PROSPECTIVE, RANDOMIZED, CONTROLLED STUDY (TRIAL REGISTRATION: Hospital S. Salvatore L'Aquila ADJ00843) conducted in 93 patients. Criteria for participation were unilateral TKA for osteoarthritis, and a preoperative hemoglobin level >13 g/dL. The outcomes measured were postoperative hemoglobin and hematocrit levels measured at 24h, 72 h, and 7 days. The mean total postoperative blood loss was calculated from drainage volume, patient blood volume, hematocrit, and red blood cell volume. In addition, the drain output within 24 h following surgery and any transfusion requirements were determined. RESULTS: Hemostatic matrix-treated patients (n = 51) showed significant reductions in calculated postoperative blood loss of 32.3% and 28.7% versus control in men and women, respectively (P < 0.01). Postoperative blood loss after 24 h in drain was significantly less with the hemostatic matrix versus control, as were decreases in hemoglobin levels 7 days post-surgery (each P < 0.01). Three patients in the control group required blood transfusion, whereas no blood transfusions were necessary in the hemostatic matrix group. CONCLUSION: The use of a hemostatic matrix provides a safe and effective means to reduce blood loss and blood transfusion requirements in TKA.

Preoperative radiofrequency ablation in painful osteolytic long bone metastases.

This study aimed to determine whether Radiofrequency Ablation (RFA) followed by prophylactic internal fixation produces better palliation in terms of pain and reduces the need for blood transfusion more than radiotherapy and surgical stabilization (RT-SS). Patients with solitary long bone metastases and a pain score of 5 or more on the VAS scale were selected. Fifteen patients were treated with RFA and surgical stabilization (RFA-SS) and were compared with a matched group (15 subjects) treated by radiotherapy and surgical stabilization (RT-SS). A complete response in terms of pain relief at 12 weeks was documented in 20% (3/15) and 533% (8/15) of the subjects treated by RT-SS or RFA-SS, respectively (p = 0.027). The overall response rate at 12 weeks was 93.3% (14 patients) in the group treated by RFA-SS and 59.9% (9 patients) in the group treated by RT-SS (p = 0.048). Although recurrent pain was documented more frequently after RT-SS (26.6%) than after RFA-SS (6.7%) the difference did not reach statistical significance. The morbidity related to RT-SS did not significantly differ when the treatment was associated with RFA. We observed a reduction in blood transfusion, as 3 patients in the RT-SS group required a blood transfusion, versus none in the RFA-SS group. Our results suggest that RFA-SS is safe and is more effective than RT-SS; furthermore, RFA may become an option for patients with metastases of the long bones to prevent tumour dissemination and reduce intraoperative blood loss. The findings described here should serve as a framework around which to design future clinical trials.

Adherence to routine use of pharmacological prophylaxis of heterotopic ossification after total hip arthroplasty: results from an Italian multicenter, prospective, observational survey.

BACKGROUND: In spite of the proven efficacy of pharmacological prophylaxis of heterotopic ossification following total hip arthroplasty, its routine use is still debated, and no data are available regarding the adherence to its administration in clinical practice. MATERIALS AND METHODS: In this prospective, observational, multicenter study, 480 consecutive patients operated on for primary total hip arthroplasty during the year 2009 were followed radiographically for 12 months after surgery in order to assess the incidence of periprosthetic heterotopic ossification. Surgeons were free to choose whether to administer pharmacological prophylaxis, and were asked to keep a record of the duration of the prophylaxis (if used) or the reasons for not using it. To facilitate the statistical analysis, all of the participating centers agreed to use only one drug (celecoxib) that had already proven to be effective. RESULTS: 368 patients were administered celecoxib and 112 patients did not receive any prophylaxis. Reported reasons for not administering celecoxib prophylaxis were the surgeon's opinion that prophylaxis was not needed on a routine basis (84/112 patients, 75%), previous history of gastrointestinal bleeding (17.8%), and concomitant cardiorenal pathologies (7.1%). The overall incidence of heterotopic ossification in the celecoxib-treated patients was 23% (no cases of Brooker grade 3 or 4 ossifications), compared to 55% in the untreated patients (Brooker grade 3 and 4: 8.9%). Multivariate analysis showed that celecoxib prophylaxis was the single most important variable when predicting the occurrence of heterotopic ossification. CONCLUSIONS: This study confirms the efficacy and tolerability of celecoxib for the prophylaxis of heterotopic ossification after total hip arthroplasty, and shows how the surgeon's belief that routine prevention is not required still plays an important role in the determination of this complication, together with the fear of possible unwanted side effects.

The use of hook plate in type III and V acromio-clavicular Rockwood dislocations: clinical and radiological midterm results and MRI evaluation in 42 patients.

BACKGROUND: Acromio-clavicular (AC) joint dislocations are very common following falls on the shoulder or an overstretched hand. The best treatment for such lesions remains a matter of debate. Several studies have, however, lent support to the surgical role of the hook plate in Rockwood type III and V AC dislocations. The aim of this study was to evaluate the midterm clinical results and magnetic resonance imaging (MRI) features of coraco-clavicular ligaments 18 months after an AC dislocation treated with an AC Dreithaler hook plate. PATIENTS AND METHODS: The cohort was made up of a consecutive series of 42 patients, who underwent surgery between November 2002 and December 2006 for an AC dislocation. They were classified, according to the Rockwood classification, as 22 grade III and 20 grade V dislocations. Surgical treatment consisted of open reduction and stabilisation with an AC Dreithaler hook plate. A clinical and radiological follow-up examination was performed 1 and 3 months after surgery, that is, before removal of the plate, and 12 months following removal. Eighteen months after the trauma, an MRI and a clinical examination were performed and the Constant-Murley scores calculated. RESULTS: An acceptable joint alignment was achieved in all the patients after surgery; 1 year after plate removal, five cases (12%) of dislocation recurrence were reported. MRI showed the coraco-clavicular ligaments had healed in the remaining 37 cases (88%). CONCLUSION: An AC plate is a useful technique in acromio-clavicular dislocations because it is easy to implant, requires mini-invasive access and results in early resumption of normal activity. MRI can be used to evaluate healing of coraco-clavicular ligaments. A long-term follow-up study is, however, warranted to assess the likelihood of recurrence. LEVEL OF EVIDENCE: Level IV, therapeutic cases series.

Clinical and radiological midterm results from using the Fixion expandable intramedullary nail in transverse and short oblique fractures of femur and tibia.

BACKGROUND: A locked nail is the principal method used to eliminate rotatory components in femoral and tibial fractures. Nevertheless, weight bearing is not directed onto the fracture site, slowing down the healing process; another possibility is to use a large-diameter nail and ream the canal to obtain as much adherence as possible and increase the grip, but this can cause a number of complications. The expandable nail is a new option that in theory should remove some problems with previous techniques. MATERIALS AND METHODS: This was a retrospective nonrandomized study encompassing 21 femoral fractures and 27 tibial fractures in 45 patients. They were classified according to the AO classification. Clinical and radiological checks were done at one, three, and six months and at one year from the surgery in order to check for signs of clinical and radiological healing. A good alignment was considered to be the presence of a deformity of less than 5 degrees in the sagittal and lateral planes and the absence of rotatory clinically evident problems. This protocol was adhered to up to six months after surgery by all of the patients, while only 62.2% performed the last control. The mean follow-up was 15 months. A second group of 48 consecutive fractures (24 femural and 24 tibial) treated with locked nail was created to compare surgical times. RESULTS: Appropriate alignment was observed in all cases; the healing process appeared slower: radiological healing occurred in most cases at six months. The following complications were reported: a case of intraoperative fracture widening with no effect on the treatment; a case of a lesion of the tip of the nail with pneumatic system rupture that necessitated nail substitution; two cases of retarded consolidation at six months, with both tibial fractures treated successfully by intralesion platelet gel; a case of incarcerated nail on 17 removals, resolved by shearing. We had no cases of clinically evident compartment syndrome or pulmonary embolism. CONCLUSIONS: The expandable Fixion nail presents significant advantages in the treatment of transverse and short oblique fractures of femur and tibia because it is easy to use, involves minimal X-ray exposure and can control rotations. Nevertheless, it high cost limits its use. We consider it as an alternative to locked nail.