Randomised controlled trial of tourniquet associated pain generated in lower limb after exsanguination by Esmarch bandage versus limb elevation.

BACKGROUND: Tourniquets are common adjuncts in the operating theatre but can be associated with post-operative pain. This study was designed to compare what effect pre-tourniquet Esmarch bandage exsanguination has on pain, compared to pre-tourniquet exsanguination by elevation alone. METHODS: 52 volunteers (104 lower limbs) were included in this study with each volunteer acting as their own matched control. The primary outcome was patient reported pain, measured in both legs simultaneously using area under curve. Secondary outcomes were pain score during inflation and deflation, cumulative pain score, duration of recovery and blood pressure during testing. RESULTS: Pain after Esmarch was superior to elevation as measured by area under pain curve (68.9 SD 26.1 vs 77.2 SD 27.3, p = 0.0010), independent of leg dominance. Cumulative pain scores demonstrated the same superiority after inflation (50.7 SD 17.1 vs 52.9 SD 17.0, p = 0.026) but not after deflation (p = 0.59). Blood pressure was not significantly different. Time to full recovery of the lower limb was the same for both groups-7.6 min (SD 2.1 min, p = 0.80). CONCLUSION: Previous studies describe a positive effect on pain when Esmarch bandage was used prior to tourniquet inflation for upper limb. Our findings suggest the same benefit from Esmarch when it was used on lower limbs-particularly during inflation of tourniquet. In addition to pain profiles, surgeon preference and patient factors need to be considered when deciding between elevation and Esmarch bandage.

Determining a reliably visible and inexpensive surface fiducial marker for use in MRI: a research study in a busy Australian Radiology Department.

OBJECTIVES: Single-use commercial surface fiducial markers are used in clinical imaging for a variety of applications. The current study sought to find a new, reliably visible, easily sourced and inexpensive fiducial marker alternative for use with MRI. DESIGN: Five commonly requested MRI sequences were determined (three-dimensional (3D) T1-weighted, T1 coronal, 3D T2-weighted, T2 fat suppressed, proton density), to examine the visibility of 18 items (including a commercial fiducial marker). SETTING: Clinical 3T MRI scanner in an Australian Tertiary Hospital and an Australian University Biomedical Engineering research group. INTERVENTIONS: 18 marker alternatives were scanned using five common MRI sequences. Images were reformatted to obtain both an image through the mid-height of each marker and a maximum intensity z-projection image over the volume of the marker. Variations in marker intensity were profiled across each visible marker and a visibility rating defined. MAIN OUTCOME MEASURES: Outcome measures were based on quantitative assessment of a clear intensity contrast ratio between the marker and the adjacent tissue and a qualitative assessment of visibility via a 3-point scale. RESULTS: The fish oil capsule, vitamin D capsule, paint ball pellet, soy sauce sushi tube and commercial markers were typically visible to a high quality on all the imaging sequences and demonstrated a clear differential in intensity contrast against the adjacent tissue. Other common items, such as plasticine 'play doh' and a soft 'Jelly baby' sweet, were surprise candidates, demonstrating high-quality visibility and intensity contrast for the 3D T1-weighted sequence. CONCLUSIONS: Depending on the basis for referral and MRI sequence chosen, four alternative fiducial markers were determined to be inexpensive, easily sourced and consistently visible. Of these, the vitamin D capsule provided an excellent balance between availability, size, cost, usability and quality of the visualised marker for all the commonly used MRI sequences analysed.

Pain and Analgesia Requirements With Hip Fracture Surgery.

BACKGROUND: Hip hemiarthroplasty and dynamic hip screw (DHS) fixation are common procedures performed in trauma units, but there is little information regarding perioperative pain experience with respect to these treatment modalities. PURPOSE: To evaluate the relationship between pain, analgesia requirements, and type of procedure for hip fracture surgery. METHODS: An analysis was performed on consecutive patients presenting with a hip fracture in 2 hospitals over 2 years. Patients with a diagnosis of dementia were excluded because of the limitations of pain assessment. Postoperative pain scores were taken from standardized patient observation charts. Perioperative opiate consumption was calculated from inpatient drug charts. RESULTS: A total of 357 patients were studied; 205 patients (53%) underwent a cemented hemiarthroplasty and 152 (47%) had fixation with a DHS. Patients who underwent a DHS fixation had more pain than those who had a hemiarthroplasty and required almost double the amount of opiates. CONCLUSION: The reason for the elevated pain scores and higher morphine requirement in the DHS group (DG) remains unclear. It could be related to highly sensitive periosteum reaction in the DG. It is important to recognize the difference in pain experienced between the groups, and analgesia should be tailored toward the individual based upon clinical assessment and knowledge of the surgery performed. A comprehensive understanding of this principle will allow for improved perioperative surgical care and patient experience.

Preliminary support for a brief psychological intervention to improve first-time hearing aid use among adults.

OBJECTIVES: Suboptimal hearing aid use extorts significant social, health, and economic costs. The aims of this study were to (1) test the novel hypothesis that the threat associated with being diagnosed with hearing loss could be ameliorated with a self-affirmation manipulation and (2) gauge the feasibility of deploying the manipulation in routine clinical practice. DESIGN: Parallel groups randomized controlled trial with 10-week follow-up. METHOD: Fifty people, newly prescribed with a hearing aid, completed either a questionnaire that included a brief self-affirming exercise or an identical questionnaire with no self-affirming exercise. The main outcome measure was derived from data logging automatically stored by the hearing aid. Perceived threat ('anxiety about ageing'), behavioural intention, and self-efficacy were measured as potential mediators. RESULTS: Objectively measured hours of daily hearing aid use were marginally higher in the intervention group compared with the control group (between-group difference = 1.94 hr, 95%CI = -1.24, 5.12, d = 0.43). At follow-up, participants in the intervention group were significantly less anxious about ageing and more accepting of older people than were participants in the control group (between-group difference = 0.75, 95%CI = 0.26, 1.22, d = 0.87). There was no statistically significant effect of the intervention on behavioural intention or self-efficacy. CONCLUSIONS: Although not statistically significant, the magnitude of the effect of the intervention on hearing aid use (d = 0.43) suggests that it would be worthwhile working towards a fully powered randomized controlled trial. The ability to reduce anxieties about ageing with this brief intervention could have far-reaching benefits for multiple patient and general population groups. Statement of contribution What is already known on this subject? Hearing impairment is more disabling than diabetes, yet hearing aid use is suboptimal. Anxieties about ageing may undermine hearing aid use. What does this study add? The study tests a brief theory-based psychological intervention to reduce anxiety about ageing and promote hearing aid use. Results show that the brief psychological intervention reduced anxiety and marginally increased objective hearing aid use. Further work is required to identify other situations in which anxieties about ageing undermine behaviour change efforts. The very brief, flexible nature of the intervention means it could be adapted and deployed in numerous other health care settings.

Fascia iliaca compartment block for hip fractures: experience of integrating a new protocol across two hospital sites.

OBJECTIVE: Fascia iliaca compartment block (FICB) administered through the loss of resistance technique effectively reduces pain and opiate requirement in elderly patients with hip fractures. FICB is a simple technique and is easily taught. This paper plots the implementation of FICB in two hospitals. METHODS: A continuous audit process of two separate sites recorded the uptake of the FICB on an organizational level. An additional control group (CG) of 100 patients were analysed to compare pain scores (using the Numerical Rating Scale) and opiate requirements between groups of patients receiving fascia iliaca block and those receiving standard care. Documentation habits and adverse drug reactions were monitored over the audit process. RESULTS: There were 434 patients audited, with 326 (75.1%) receiving the FICB. The uptake of the FICB and documentation improved over time. The FICB significantly reduced pain scores (P<0.001) and also opiate requirement (P<0.0001) compared with those in the CG. Acute length of stay reduced to 9.9 days (FICB group) from 15 days (CG). Inpatient mortality was 5.5% in the FICB group and 15% in the CG (P=0.0024). CONCLUSION: Organizational learning of this simple procedure can be achieved through a multidisciplinary approach, and committed departmental education and feedback. The impact on length of stay and mortality were striking; however, there may be other confounding factors. Only two cases of true anaesthetic toxicity occurred in 1586 patients. The authors conclude that FICB is a safe procedure and a useful adjunct for preoperative pain control in patients with hip fractures.

Local Anaesthetic Infiltration and Indwelling Postoperative Wound Catheters for Patients with Hip Fracture Reduce Death Rates and Length of Stay.

Background. An analgesic enhanced recovery (ER) protocol for patients with a hip fracture was introduced. It was hypothesised that the ER would reduce pain, length of stay and improve clinical outcomes. The protocol used intraoperative infiltration of levobupivacaine followed by ongoing wound infusions. Methods. Consecutive patients admitted to two hospitals were eligible for the ER protocol. Numerical Reporting Scale pain scores (0-10) were recorded alongside opiate requirements. 434 patients in the ER group (316 full ER, 90 partial ER, and 28 no ER) were compared to a control group (CG) of 100 consecutive patients managed with traditional opiate analgesia. Results. Mean opiate requirement was 49.2 mg (CG) versus 32.5 mg (ER). Pain scores were significantly reduced in the full ER group, p < 0.0001. Direct discharge home and mean acute inpatient stay were significantly reduced (p = 0.0031 and p < 0.0001, resp.). 30-day mortality was 15% (CG) versus 5.5% (ER), p = 0.0024. Conclusions. This analgesic ER protocol for patients with a hip fracture was safe and effective and was associated with reduced inpatient stay and mortality.

Cemented hemiarthroplasty or hip replacement for intracapsular neck of femur fracture? A comparison of 7732 matched patients using national data.

BACKGROUND: The treatment of choice for intracapsular neck of femur (NOF) fractures in younger, more active patients remains unknown. Some surgeons advocate total hip replacement (THR). AIM: This study aimed to compare complications following THR and hemiarthroplasty using the Hospital Episode Statistics (HES) database in England. METHOD: Dislocation and revision rates were extracted for all patients with NOF fracture who underwent either cemented hemiarthroplasty or cemented THR between January 2005 and December 2008. To make a 'like for like' comparison all 3866 THR patients were matched to 3866 hemiarthroplasty patients (from a total of 41,343) in terms of age, sex and Charlson score. RESULTS AND CONCLUSION: Eighteen-month dislocation was significantly higher in the THR group (2.4% vs. 0.5%, odds ratio (OR) 3.90 (2.99-5.05), p<0.001). This difference was sustained at the 4-year stage (2.9% vs. 0.9%, OR 3.18 (1.58-6.94), p=0.001) in a subset of patients with longer follow-up. There was no significant difference in revision rate up to 4 years (1.8% vs. 2.1%, OR 0.85 (0.46-1.55), p=0.666). In this national analysis of matched patients short- and medium-term dislocation rates following THR were significantly higher than following cemented hemiarthroplasty, without any difference in revision rates at 4 years. The low risk of dislocation may be acceptable in order to experience the apparent functional benefits of THR.

Henry's pelvic deltoid: antiquated concept or important consideration for total hip arthroplasty? An anatomical study.

The relevance of Henry's pelvic deltoid and its contribution to hip abductor strength is often not considered in hip arthroplasty. This small cadaveric study (n = 11) aimed to quantify the relative contributions of the pelvic deltoid muscles to abductor strength and to assess how different surgical approaches(anterolateral, direct lateral and posterior) impact on each of these muscle groups. We inspected the path of each approach and measured the cross-sectional area of the hip abductors, from which the contribution of each muscle to abductor moment was derived. We concluded that the posterior approach has the least impact on the pelvic deltoid and overall abductor moment.