Can total wrist arthroplasty be an option in the treatment of the severely destroyed posttraumatic wrist?

Background Severely destroyed posttraumatic wrists are usually treated by partial or total wrist fusion or proximal row carpectomy. The indications for and longevity of total wrist arthroplasty (TWA) are still unclear. Case Description The aim of this study was to analyze a series in which one last-generation total wrist arthroplasty was used as a salvage procedure for wrists with severe arthritis due to traumatic causes. The data were prospectively recorded in a web-based registry. Seven centers participated. Thirty-five cases had a minimum follow-up time of 2 years. Average follow-up was 39 (24-96) months. Pain had improved significantly at follow-up, mobility remained unchanged. The total revision rate was 3.7%, and the implant survival was 92% at 4-8 years. Literature Review Very few studies have described specific results after TWA in posttraumatic cases and almost none using classical "third-generation" implants. The number of cases and the follow-up in the published series are small. Clinical Relevance Although painful posttraumatic wrists with severe joint destruction can be salvaged by partial or total fusion, we found that, evaluated at short- to midterm, total wrist arthroplasty can be an alternative procedure and gives results that are comparable to those obtained in rheumatoid cases. Level IV Case series.

Heart rate variability in complex regional pain syndrome during rest and mental and orthostatic stress.

BACKGROUND: Complex regional pain syndrome (CRPS) is a pain condition with regional sensory and autonomic abnormalities in the affected limb. The authors studied systemic autonomic and hemodynamic function in CRPS patients during rest, and during orthostatic and mental arithmetic stress. METHODS: Twenty patients with CRPS and 20 age-, sex-, and body mass index-matched control subjects participated. Mean values of heart rate variability, baroreceptor sensitivity, blood pressure, stroke volume, cardiac output, and total peripheral resistance were estimated during supine rest and 60° tilt-table testing. On a separate day, heart rate variability was also measured during mental arithmetic stress testing induced by a paced auditory serial addition task. RESULTS: Heart rate was increased and heart rate variability reduced in patients with CRPS patients compared with control subjects during rest and mental and orthostatic stress, whereas baroreceptor sensitivity was unaffected. When tilted from supine to upright position, patients with CRPS were not able to preserve cardiac output in comparison with control subjects, and they exhibited an exaggerated increase in the total peripheral resistance. The hemodynamic changes correlated to pain duration but not to pain intensity. CONCLUSION: The increased heart rate and decreased heart rate variability in CRPS suggest a general autonomic imbalance, which is an independent predictor for increased mortality and sudden death. The inability of the patients to protect their cardiac output during orthostatic stress was aggravated with the chronicity of the disease.

Neuroma removal for neuropathic pain: efficacy and predictive value of lidocaine infusion.

OBJECTIVE: Injury to peripheral nerves associated with trauma, amputation, or surgery may lead to the formation of neuromas that can produce severe pain refractory to pharmacotherapy. Ectopic impulse activity arising in blindly ending axons within the neuroma, which contain abnormal accumulations of sodium channels, is thought to be a major contributor to this pain. The effect of surgical excision has remained controversial. Here we report a prospective study on the effect of neuroma removal on pain. METHODS: A series of 6 patients with chronic neuropathic pain owing to neuromas after nerve injury were studied before and 3 months after neuroma excision. Quantitative sensory testing included measurement of areas of brush-evoked allodynia, pinprick hyperalgesia, and mechanical and thermal thresholds. The hypothesis that the analgesic response to a preoperative, intravenous infusion of the sodium channel blocker lidocaine can predict outcome of surgery was also tested. RESULTS: Surgery only relieved spontaneous pain in 2 out of the 6 patients. One of those patients had a prior poor response to neuroma removal. In one patient the pain worsened. Response to surgical removal of neuromas was not predicted by the response to preoperative infusion of intravenous lidocaine. DISCUSSION: Our findings suggest that, as a therapeutic maneuver, surgical excision of neuromas should be reserved for only those patients with intractable pain, who have failed to respond to other therapies. However, prior poor response to neuroma removal does not preclude relief of pain after a new excision.

Safety of lornoxicam in the treatment of postoperative pain: a post-marketing study of analgesic regimens containing lornoxicam compared with standard analgesic treatment in 3752 day-case surgery patients.

BACKGROUND: Post-marketing surveillance studies can provide supplemental data on the safety of medications in the general population. OBJECTIVE: This study aimed to evaluate the safety of analgesic regimens including the NSAID lornoxicam in the short-term treatment of postoperative pain in a clinically relevant population. STUDY DESIGN: Randomized, open-label, multicentre, multinational, observational cohort study of 4 days' duration. SETTING: In-hospital postoperative setting, with discharge to home treatment within 24 hours of surgery. PARTICIPANTS: Adults aged > or =18 years expected to be in need of analgesic treatment after day-case surgery. INTERVENTION: Analgesic regimens containing lornoxicam were compared with a standard analgesic treatment, which was defined as the treatment that the patient would normally receive at the centre. MAIN OUTCOME MEASURES: Following day-case surgery, patients were provided with appropriate analgesic medication, and adverse events (AEs; defined as all recorded events with symptoms) were recorded by the investigator during the in-hospital stay and by the patient for the next 3 days using entries recorded morning and evening in a patient diary. Statistical analyses tested for between-treatment differences in AEs, adverse drug reactions (ADRs; defined as events probably, possibly or unlikely to be related to treatment) and gastrointestinal AEs (GI-AEs). RESULTS: A total of 4152 patients were randomized to treatment. Since 400 patients did not take any analgesic, the safety population consisted of 1838 patients for lornoxicam and 1914 patients for standard analgesic treatment. Demographic and disease characteristics were similar between the two treatment groups, as were the type of surgery and the anaesthesia used in surgery. In the safety population, 16.9% of patients received no analgesic in hospital, and when analgesics were provided they were often administered in combination. Similarly, approximately 17% of patients did not take any analgesics at home. AEs were reported in 27.1% and 29.4% of patients in the lornoxicam and standard analgesic treatment groups, respectively, and ADRs constituted the majority of these events. No significant differences were demonstrated with regard to the incidence of AEs between the two groups. Most events were of mild or moderate intensity. Consistent with what may be expected for an NSAID, most AEs with lornoxicam were related to the GI system. GI-AEs were reported in 19.5% and 21.3% of patients in the lornoxicam and standard analgesic treatment groups, respectively, and most of these were considered ADRs. Most patients were satisfied with their pain treatment both in hospital and at home. CONCLUSION: Lornoxicam-containing regimens are as well tolerated as other analgesic regimens over 4 days in the treatment of postoperative pain.

Multiple sodium channel isoforms and mitogen-activated protein kinases are present in painful human neuromas.

OBJECTIVE: Although axons within neuromas have been shown to produce inappropriate spontaneous ectopic discharges, the molecular basis for pain in patients with neuromas is still not fully understood. Because sodium channels are known to play critical roles in neuronal electrogenesis and hyperexcitability, we examined the expression of all the neuronal voltage-gated sodium channels (Nav1.1, Nav1.2, Nav1.3, Nav1.6, Nav1.7, Nav1.8, and Nav1.9) within human painful neuromas. We also examined the expression of two mitogen-activated protein (MAP) kinases, activated p38 and extracellular signal-regulated kinases 1 and 2 (ERK1/2), which are known to contribute to chronic pain, within these human neuromas. METHODS: We used immunocytochemical methods with specific antibodies to sodium channels Nav1.1, Nav1.2, Nav1.3, Nav1.6, Nav1.7, Nav1.8, and Nav1.9, and to activated MAP kinases p38 and ERK1/2 to study by confocal microscopy control and painful neuroma tissue from five patients with well-documented pain. RESULTS: We demonstrate upregulation of sodium channel Nav1.3, as well as Nav1.7 and Nav1.8, in blind-ending axons within human painful neuromas. We also demonstrate upregulation of activated p38 and ERK1/2 MAP kinases in axons within these neuromas. INTERPRETATION: These results demonstrate that multiple sodium channel isoforms (Nav1.3, Nav1.7, and Nav1.8), as well as activated p38 and ERK1/2 MAP kinases, are expressed in painful human neuromas, indicating that these molecules merit study as possible therapeutic targets for the treatment of pain associated with traumatic neuromas.

Phantom-related phenomena after rectal amputation: prevalence and clinical characteristics.

Phantom sensations are well known and almost inevitable sequels to limb amputation, whereas similar phenomena are only rarely described after rectum amputation (phantom rectum). Our study attempted to assess the frequency and character of phantom rectum. All surviving patients (n = 22), who had undergone abdominoperineal surgical resection of the rectum in the period 1980-1986 at our clinic, were interviewed by a standard questionnaire and underwent a physical examination. Sixty-eight per cent of the patients experienced a sensation of a missing rectum (phantom rectum), and in 27% of these or 18% of all patients this sensation was painful (phantom pain). The most common symptoms were sensations of flatus and/or faeces in a normal rectum, phantom flatus or phantom faeces. The phantom pains were described as either pricking and shooting or like haemorrhoids or hard stools that would rupture the rectum. Neither age, sex, preoperative pain, the Duke classification of the tumour nor the healing of the perineal wound seemed related to the likelihood of phantom rectum. The pathophysiological mechanisms underlying phantom-related phenomena following amputation have not yet been elucidated. This study describes a relatively unknown phantom-related clinical entity after amputation and may thus contribute to the understanding of this phenomenon.

Codeine plus paracetamol versus paracetamol in longer-term treatment of chronic pain due to osteoarthritis of the hip. A randomised, double-blind, multi-centre study.

This randomized, double-blind, multi-centre study was undertaken to evaluate the efficacy and safety of treatment for 4 weeks with codeine plus paracetamol versus paracetamol in relieving chronic pain due to osteoarthritis of the hip. A total of 158 outclinic patients entered the study. Eighty-three patients (mean age 66 years) were treated with codeine 60 mg plus paracetamol 1 g 3 times daily, and 75 patients (mean age 67 years) with paracetamol 1 g 3 times daily. Ibuprofen 400 mg was prescribed as rescue medication. Due to an unexpected high rate of adverse drug reactions, the study was closed before the planned 400 patients had entered. Over weeks 1-4, 87%, 64%, 61% and 52% of patients in the codeine plus paracetamol group, and 38%, 31%, 22% and 29% of patients in the paracetamol group had one or more adverse drug reactions. Significantly more patients in the codeine plus paracetamol group had adverse drug reactions in each of the 4 weeks. Nausea, dizziness, vomiting and constipation were predominant adverse reactions in the codeine plus paracetamol group. During the first week of treatment, 30 patients (36%) in the codeine plus paracetamol group and 9 (12%) in the paracetamol group dropped out. As evaluated from patients completing the first week of treatment, the pain intensity during that week compared to their baseline pain was significantly lower in the codeine plus paracetamol group than in the paracetamol group. Moreover, during the first week the paracetamol group received rescue medicine significantly more frequently. In conclusion, when evaluated after 7 days of treatment, the daily addition of codeine 180 mg to paracetamol 3 g significantly reduced the intensity of chronic pain due to osteoarthritis of the hip joint. However, several adverse drug reactions, mainly of the gastrointestinal tract, and the larger number of patients withdrawing from treatment means that the addition of such doses of codeine cannot be recommended for longer-term treatment of chronic pain in elderly patients.

Immediate and long-term phantom breast syndrome after mastectomy: incidence, clinical characteristics and relationship to pre-mastectomy breast pain.

Phantom breast syndrome (PBS) following mastectomy has already been reported by other authors. The temporal course, character and extent of these phenomena, however, have not yet been elucidated. In a prospective study, we investigated the incidence, clinical picture and the temporal course of PBS. One hundred and twenty women who, during a 1 year period, embarked consecutively on post-operative control or treatment at the department, were interviewed by a standard questionnaire 3 weeks after the operation. One year later 110 patients were interviewed again. The median age at the first interview was 54 years (Q1 = 45 years; Q3 = 62 years). The incidence of PBS was 25.8% at the first interview and 24.5% at the second. The incidence of phantom pain and non-painful phantom sensations was 13.3% and 15.0%, respectively, 3 weeks after mastectomy and 12.7% and 11.8%, respectively after 1 year. We found significant relationships between pre-operative pain and PBS, but no significant relation between age and the occurrence of PBS. Neither post-operative sequelae nor cancer treatment including radiotherapy seemed to affect the occurrence of PBS. Exteroceptive-like pain emerged as the most predominant type of pain from both interviews. At the time of the first interview, 35.0% of the patients experienced cicatrix pain which was clearly distinguishable from phantom pain; after 1 year, 22.7% of the patients had persistent cicatrix pain. The present incidence of PBS is close to the incidence reported by others. Persistent phantom pain may, however, be more common than usually expected. Also persistence of cicatrix pain seems to be more common than generally expected.