Postoperative pain following primary lower limb arthroplasty and enhanced recovery pathway.

INTRODUCTION: Enhanced recovery is a concept that has become increasingly popular for arthroplasty surgery over the last ten years. This study was designed to assess the analgesia requirements, pain levels and time to discharge for patients having primary arthroplasty in the enhanced recovery pathway. METHODS: A multidisciplinary prospective cohort study was carried out between January 2012 and March 2012. Data were collected for patients undergoing primary arthroplasty in one hospital during this time. Details of anaesthesia, local infiltration, additional medications and analgesia were recorded. A visual analogue scale pain score was obtained from each patient at time of mobilisation on days 0, 1, 2 and 3 postoperatively. RESULTS: Ninety-six patients were included in the study. Of these, 34 underwent total hip arthroplasty and 62 total knee arthroplasty (TKA). Pain was the greatest contributor for delayed discharge in TKA patients. The patients who had TKA and did not receive non-steroidal anti-inflammatory drugs (NSAIDs) had significantly higher pain scores (day 0, p<0.01; day 1, p<0.001; day 2, p<0.01) and significantly increased opiate demands compared with those patients who did receive NSAIDs. CONCLUSIONS: There are unacceptably high pain scores in patients undergoing TKA without the use of NSAIDs. There should be focused intervention with this group of patients to improve their pain scores and reduce their length of stay.

Is revision surgery following lower-limb amputation a worthwhile procedure? A retrospective review of 71 cases.

There is little written about the value of revision surgery on lower-limb amputations. We report on 71 revision amputation procedures performed by a single surgeon in this retrospective analysis. The majority of our revisions (61%) were in amputees who had suffered trauma. We judged success from a surgical and a rehabilitation perspective using scoring systems. Revisions for bony and soft-tissue pathology had good outcomes from a surgical (85% and 82%) and a rehabilitation perspective. Revisions for infection had satisfactory results from a surgical perspective (73%) but less so from a rehabilitation perspective (25%). The results of the revisions for pain were poor showing surgical success only 50% of the time where a neuroma was suspected and only 25% when there was no apparent cause. There was little or no improvement in rehabilitation in both the pain groups. Revision surgery for certain pathologies gives a good surgical outcome and can improve pain and mobility status. Patient selection for surgery is key and evaluation by a multidisciplinary team is recommended.

Transient femoral nerve palsy associated with a synovial cyst of the hip in a patient with spinal cord injury.

We report a case of local compression-induced transient femoral nerve palsy in a 46-year-old man. He had previously undergone surgical release of the soft tissues anterior to both hip joints because of contractures following spinal injury. An MRI scan confirmed a synovial cyst originating from the left hip joint, lying adjacent to the femoral nerve. The cyst expanded on standing, causing a transient femoral nerve palsy. The symptoms resolved after excision of the cyst.

Rehabilitation of the trans-femoral amputee with an osseointegrated prosthesis: the United Kingdom experience.

Osseointegration for the trans-femoral amputee has been used in the United Kingdom since 1997. To date, 11 candidates have undergone the procedure. The rehabilitation programme for the osseointegration candidate is a long and intensive programme following two surgical operations. This paper outlines the importance of a pre-osseointegration assessment to explore candidates' suitability and expectations for the procedure. The physical and prosthetic advantages of direct skeletal attachment have led to improvements in candidates' comfort, function and quality of life. However, some aspects of this promising developmental procedure for the management of the trans-femoral amputee need to be critically evaluated before it becomes a routine clinical procedure in the United Kingdom.

Disarticulation at the ankle using an anterior flap. A preliminary report.

Disarticulation has been carried out in ten ankles in nine patients in whom it was not possible to use a heel flap. Four patients were able to walk with a prosthesis which gave satisfactory function. In five who were bedridden, healing was achieved and was of sufficient quality to allow transfers. There was no operative morbidity or mortality. This technique can be used instead of a transtibial amputation if necrosis or ischaemia of the heel is a contraindication to conventional Syme's amputation.

Cbl-mediated negative regulation of platelet-derived growth factor receptor-dependent cell proliferation. A critical role for Cbl tyrosine kinase-binding domain.

The Cbl proto-oncogene product has emerged as a novel negative regulator of receptor and non-receptor tyrosine kinases. Our previous observations that Cbl overexpression in NIH3T3 cells enhanced the ubiquitination and degradation of the platelet-derived growth factor receptor-alpha (PDGFRalpha) and that the expression of oncogenic Cbl mutants up-regulated the PDGFRalpha signaling machinery strongly suggested that Cbl negatively regulates PDGFRalpha signaling. Here, we show that, similar to PDGFRalpha, selective stimulation of PDGFRbeta induces Cbl phosphorylation, and its physical association with the receptor. Overexpression of wild type Cbl in NIH3T3 cells led to an enhancement of the ligand-dependent ubiquitination and subsequent degradation of the PDGFRbeta, as observed with PDGFRalpha. We show that Cbl-dependent negative regulation of PDGFRalpha and beta results in a reduction of PDGF-induced cell proliferation and protection against apoptosis. A point mutation (G306E) that inactivates the tyrosine kinase binding domain in the N-terminal transforming region of Cbl compromised the PDGF-inducible tyrosine phosphorylation of Cbl although this mutant could still associate with the PDGFR. More importantly, the G306E mutation abrogated the ability of Cbl to enhance the ligand-induced ubiquitination and degradation of the PDGFR and to inhibit the PDGF-dependent cell proliferation and protection from apoptosis. These results demonstrate that Cbl can negatively regulate PDGFR-dependent biological responses and that this function requires the conserved tyrosine kinase binding domain of Cbl.

Through-knee amputation in high-risk patients with vascular disease: indications, complications and rehabilitation.

During a 10-year period 104 patients (mean age 72 years) had 106 through-knee amputations. Indications for surgery were: limb gangrene, 67 (64 per cent); ischaemic ulceration, 22 (21 per cent); rest pain, 9; knee contractures, 6. Thirty patients had had previous unsuccessful vascular reconstructive surgery and five had had a failed femoral embolectomy. The through-knee disarticulation used lateral skin flaps. The mortality was 21 (20 per cent). Of the 83 survivors, 59 (71 per cent) underwent uncomplicated primary wound healing; 36 (43 per cent) of the survivors were unsuitable for rehabilitation on a prosthesis. The remaining 47 (57 per cent) were walking before discharge 30-130 days (mean 68 days) after amputation. Through-knee amputation is a rapid, relatively bloodless, amputation and is a useful debridement procedure. The many surgical and functional advantages, in conjunction with the recent reports of better rehabilitation compared with the above-knee or Gritti-Stokes amputation, suggests that the through-knee amputation deserves greater consideration.

Post-amputation pneumatic walking aid.

A pneumatic walking training aid is described that has been developed by the Biomechanical Research and Development Unit, Roehampton, from the original design by Little. The new design has been used in the management of 87 amputations, including 44 patients over the age of 70. Ninety-four per cent of these patients were rehabilitated to walking independently on a pylon or prosthesis.

Long posterior flap amputation in geriatric patients with ischaemic disease.

A series of 165 primary amputations performed on 148 patients at Queen Mary's Hospital, Roehampton, from 1967 to 1975 is reported. The average age of these patients was 70 years, the oldest being 95. Those aged 70 years and over are considered in special detail. The problems of management of these elderly patients are complex, involving medical, surgical, and social problems. The object of treatment is to restore these patients to their previous way of life with the shortest possible time in hospital. Every patient is assessed with a view to arterial surgery, and amputation is avoided where possible by a lumbar sympathetic block or direct arterial surgery. When amputation cannot be avoided a below-knee level is selected if possible. A long posterior flap technique is used which forms a myoplasty of the gastrocnemius muscle; thus the ischaemic anterior tibial skin is avoided. Before the operation the patient is assessed by a specialist team and the management is discussed in detail. Every patient is kept in hospital until rehabilitation is achieved to the point of independence inside the home. Of the 90 patients in the group aged 70 years and over, 22% had above-knee amputations and 75% had below-knee amputations, with the result that 69% of the latter were discharged home walking. This result is contrasted with the smaller number who had an above-knee amputation. Below-knee amputation gives the elderly patient a better chance of walking because of the use of the patellar tendon bearing prosthesis. When followed up 36% of those patients with below-knee amputation were fully independent for periods exceeding six months. The price of a below-knee level of amputation is a longer hospital stay, but the quality of function and mobility obtained by the patient makes this worth while.

Immediate operative fitting of upper limb prosthesis at the time of amputation.

Three patients are described--2 with an above-elbow amputation and 1 with a through-wrist amputation--in whom a temporary prosthesis was applied on the operating table and in all of whom function was rapidly established. The patients did not become one-handed, with the result that they have all continued to wear their prosthesis throughout their working hours and use their artificial hand for all everday functions. The value of this technique in making the patient accept the prosthesis and therefore to make full use of it suggests that this procedure should be more widely applied in patients who require upper limb amputation.