Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery.

This randomised, double-blind, placebo-controlled study compared the effect of perineural with intravenous dexamethasone, both administered concomitantly with interscalene brachial plexus block for shoulder surgery. Patients received 8 mg dexamethasone mixed with ropivacaine in the block injection (n = 42), 8 mg dexamethasone intravenously at the time of the block (n = 37), or intravenous saline (n = 41) at the time of the block. Perineural and intravenous dexamethasone resulted in prolonged mean (SD) duration of block to 16.9 (5.2) h and 18.2 (6.4) h, respectively, compared with 13.8 (3.8) h for saline (p = 0.001). Mean (SD) opioid consumption (morphine equivalents) during the first 24 h after postanaesthesia recovery arrival was 12.2 (9.3) mg in the perineural dexamethasone, 17.1 (15.9) mg in the intravenous dexamethasone and 24.1 (14.3) mg in the saline groups (p = 0.001). Dexamethasone via either route reduced anti-emetic use (p = 0.046). There was no effect on patient satisfaction. These results suggest that both perineural and intravenous dexamethasone are useful adjuncts to ropivacaine interscalene block, with the intravenous route preferred as this avoids the possibility of neural toxicity of dexamethasone.

Percutaneous in situ versus open arthrodesis of the distal interphalangeal joint.

We compared the results of percutaneous in situ arthrodesis with open arthrodesis of the distal interphalangeal joint with a headless compression screw. In the percutaneous in situ arthrodesis group (17 joints), the screw was inserted from the fingertip across the unprepared joint. In the open group (12 joints), flat cancellous surfaces were prepared before screw insertion. Solid fusion was found in 10/17 joints (59%) with percutaneous in situ arthrodesis and in 11/12 joints (92%) with open arthrodesis. Among the other seven joints with percutaneous in situ arthrodesis, six had fibrous union and were asymptomatic at a mean of 18 months, and one failed, requiring revision. One joint with open arthrodesis had fibrous union and was asymptomatic 12 months after surgery. We conclude that open arthrodesis is better than the percutaneous method, as a greater percentage achieve bone union. The open approach allows osteophyte removal and slightly better correction of angular deformity in the coronal plane.

Evaluation of serum osteoblast mitogenic activity in spinal cord and head injury patients with acute heterotopic ossification.

STUDY DESIGN: This was a blind, prospective study of the effect of sera from patients with spinal cord and head injuries on osteoblast proliferation. OBJECTIVES: The authors studied whether a humoral factor that stimulates the formation of heterotopic bone is released into the circulation after a neural injury. BACKGROUND DATA: Other authors have shown that a humoral osteoinductive factor may be released after head and spinal cord injuries. METHODS: Serum was obtained at certain times throughout the first 12 weeks post-injury and from control subjects. It was incubated with osteoblasts harvested from fetal rats, as well as with fibroblast controls. RESULTS: There was a significant rise in serum mitogenic activity after injury in both groups. When patients that developed heterotopic ossification were compared to other patients and controls, no significant differences were seen. CONCLUSIONS: This in vitro study fails to support a humoral mechanism for heterotopic ossification after spinal cord or brain injuries.

Treatment of heterotopic ossification after spinal cord injury.

A new protocol in management of heterotopic ossification (HO) was evaluated in 46 patients after spinal cord injury (SCI). A group of 24 paraplegic and 22 tetraplegic patients was involved in a prospective study. Diagnosis of HO was made by bone scintigraphy and radiographic evaluation. Patients were divided into two groups. Group I was made up of 33 patients with positive bone scintigraphy and negative evidence of HO and Group II was made up of 13 patients with positive bone scintigraphy and positive radiographic evidence of HO. Etidronate was started intravenously (300 mg/day) for three days followed by oral therapy for six months (20 mg/kg/day). Follow-up of patients was 15.7 +/- 8 months after SCI. In Group I, etidronate therapy prevented the development of HO in 79 percent of patients; in 21 percent of patients, a low degree of tissue ossification was found which was not clinically significant. In Group II, there was an inhibitory effect of etidronate on progression of soft tissue ossification in six patients. The remaining seven patients did not respond to therapy and showed an increased growth of HO. Our data indicate that etidronate may prevent HO in the majority of patients when administered at an early stage of HO development and in higher doses than are routinely recommended.

Functional outcome following salvage of failed trapeziometacarpal joint arthroplasty.

The outcomes in 12 patients who underwent revision surgery for a failed trapeziometacarpal joint arthroplasty were assessed. Multiple procedures were common (an average of 4.5 per patient), and associated with an overall complication rate of 27%. However, after an average follow-up of 5 years, nine of the 12 patients reported improved function and ability to complete normal daily tasks. Most patients were satisfied with their level of pain relief, their grip and pinch strength, and their overall final result. The subjective outcome was less satisfactory in those involved in workers' compensation litigation. All seven attempted scaphoid-thumb metacarpal fusions failed.

Surgical correction of extensor tendon subluxation and ulnar drift in the rheumatoid hand: long-term results.

Subluxation of the extensor digitorum communis tendons in the rheumatoid hand causes ulnar digital drift. If passively correctable, the digit may be realigned by soft tissue rebalancing and extensor centralization, which may preserve a more functional arc of motion than achieved with arthroplasty. A total of 71 centralization procedures were done in 15 rheumatoid patients with a mean age of 55 years and an average follow-up of 9 years. A distally based central-third strip of extensor tendon was used. Correction of ulnar drift deformity was from an average of 47 degrees preoperatively to 7.9 degrees postoperatively, and correction of active range of motion of the metacarpophalangeal joints was from an average of 38 degrees to 56.2 degrees. Reoperation and complication rates were low. This technique corrects and maintains ulnar drift in the rheumatoid hand. Range of motion at the metacarpophalangeal joint level is improved and converted to a more functional one by decreasing the extensor lag.