Perioperative pregabalin does not reduce opioid requirements in total knee arthroplasty.

PURPOSE: The purpose of this prospective, randomized, double-blinded, placebo-controlled study was to determine if pregabalin, when given perioperatively in addition to patient-controlled analgesia morphine, paracetamol and etoricoxib, is effective in reducing morphine requirements and moderating pain scores after primary total knee arthroplasty. We hypothesize that there would be no difference in postoperative opioid requirements, postoperative pain scores, and functional scores with the use of perioperative pregabalin. METHODS: Eighty-seven patients who underwent primary total knee arthroplasty were randomised and allocated to two groups. One group received capsules containing pregabalin 75 mg, and the other a placebo-one capsule before surgery and one capsule once per night up till postoperative day 2. Multimodal analgesia provided for all patients in this study included femoral nerve block, intravenous patient-controlled analgesia (morphine), paracetamol and etoricoxib. The primary outcome of patient's pain control was based on the measurement of cumulative morphine consumption during the first 72 h postoperatively. RESULTS: Pregabalin did not reduce the cumulative or effective morphine consumption at 48 h and 72 h post-operation. There were also no significant differences noted in pain scores at 48 h and 72 h after surgery, functional range of motion of the operated knee at 72 h post-op, or outcomes recorded on the Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and 36-Item Short Form Survey (SF-36) questionnaires at 3 and 6 months post-op. None of the patients demonstrated common adverse reactions to pregabalin. CONCLUSION: This study showed no reduction in postoperative opioid requirements, or improvement in early postoperative pain scores or functional outcomes at 6 months, with perioperative use of pregabalin. Orthopaedic surgeons may consider this when selecting an analgesic regimen for their patients. LEVEL OF EVIDENCE: II.

Accuracy of sacroiliac screw placement with and without intraoperative navigation and clinical application of the sacral dysmorphism score.

INTRODUCTION: Percutaneously-placed sacroiliac (SI) screws are currently the gold-standard fixation technique for fixation of the posterior pelvic ring. The relatively high prevalence of sacral dysmorphism in the general population introduces a high risk of cortical breach with resultant neurovascular damage. This study was performed to compare the accuracy of SI screw placement with and without the use of intraoperative navigation, as well as to externally validate the sacral dysmorphism score in a trauma patient cohort. PATIENTS AND METHODS: All trauma patients who underwent sacroiliac screw fixation for pelvic fractures at a level 1 trauma centre over a 6 year period were identified. True axial and coronal sacral reconstructions were obtained from their pre-operative CT scans and assessed qualitatively and quantitatively for sacral dysmorphism - a sacral dysmorphism score was calculated by two independent assessors. Post-operative CT scans were then analysed for breaches and correlated with the hospital medical records to check for any clinical sequelae. RESULTS: 68 screws were inserted in 36 patients, most sustaining injuries from road traffic accidents (50%) or falls from height (36.1%). There was a male preponderance (83.3%) with the majority of the screws inserted percutaneously (86.1%). Intraoperative navigation was used in 47.2% of the patient cohort. 30.6% of the cohort were found to have dysmorphic sacra. The mean sacral dysmorphism scores were not significantly different between navigated and non-navigated groups. Three cortical breaches occurred, two in patients with sacral dysmorphism scores >70 and occurring despite the use of intraoperative navigation. There was no significant difference in the rates of breach between navigated and non-navigated groups. None of the breaches resulted in any clinically observable neurovascular deficit. CONCLUSION: The sacral dysmorphism score can be clinically applied to a cohort of trauma patients with pelvic fractures. In patients with highly dysmorphic sacra, reflected by high sacral dysmorphism scores, intraoperative navigation is not in itself sufficient to prevent cortical breaches. In such patients it would be prudent to consider instrumentation of the lower sacral corridors instead.

A novel technique for modified all-inside repair of bucket-handle meniscus tears using standard arthroscopic portals.

BACKGROUND: Bucket-handle meniscus tears (BHMT) are often displaced and unstable. The inside-out technique of repairing such tears is currently the gold standard. All-inside repair with meniscal fixators is getting increasingly popular. Shortcomings of the inside-out technique include neurovascular complications, especially saphenous nerve palsy, and retention of a non-resorbable suture which can result in discomfort to patient, granuloma formation, and a foci of infection. Hence, the purpose of this project was to innovate a novel all-inside technique to precisely reduce and fix BHMT while avoiding neurovascular complications and retention of a non-resorbable suture. METHODS: Routine arthroscopic portals were created on a patient's left knee with a displaced BHMT. Through the anteromedial portal, a conjoint pseudo double lumen cannula was inserted. Two limbs of a reduction suture were passed through the cannula, one over the "femoral" surface of the meniscus, one over the "tibial" surface of the meniscus anterior to the biceps femoris tendon, with the knee flexed at 20° to avoid injury to the saphenous nerve. Suture limbs were passed out percutaneously and tensioned. RESULTS: Anatomic reduction was ensured under arthroscopic visualization with ease. All inside repair was performed using the vertical mattress suture configuration. Reduction sutures were subsequently removed by cutting flush to the skin and pulling on one suture limb. The patient was back to full activities with minimal discomfort 8 months post-operatively. CONCLUSION: The technique described is superior to existing techniques for the following reasons: (1) Reduction of the displaced meniscal tear is "extra-meniscal," avoiding further trauma to a damaged meniscus. (2) Tensioning of the two suture limbs created promotes better control of reduction through tensioning. (3) Risk of discomfort, infection, and neurovascular damage caused by a retained suture is reduced. (4) No additional portals/equipment is required. We encourage this novel technique to be attempted by surgeons.

Orofacial dystonia triggered by mouth closure.

Focal task-specific dystonia affects one part of the body, occurring only during the performance of a specific task. It usually affects the hand, though it can rarely affect the orofacial region. Treatment with oral medications and botulinum toxin (BTX) usually produces only modest benefit, owing to the complexity of the movements involved. We describe a patient with an unusual form of focal task-specific orofacial dystonia, manifested by asynchronous twitching of the right and left lower hemiface upon closure of the mouth and pursing of the lips. Injection of BTX produced complete resolution of task-specific dystonia for 4.5 months.