A Prospective Comparative Study of Post Total Knee Arthroplasty Pain Management by Epidural vs Local Infiltration.

In a randomized controlled trial, we compared whether local infiltration analgesia would result in better pain management after total knee arthroplasty (TKA) than epidural analgesia (EA). Two groups were made with 30 patients each. Group local infiltration analgesia (LIA) with a total of 30 patients (mean age of 65 years) received LIA with a periarticular injection of a mixture of ropivacaine, adrenaline, and ketorolac that was prepared under strict sterile conditions. In group EA, 30 patients (mean age of 67 years) were given EA. There was no statistically significant difference of pain at rest. The mean opioid consumption was higher in those receiving local infiltration. Most secondary outcomes were similar, but EA patients had lower pain scores when walking and during continuous passive movement. If EA is not readily available, local infiltration provides similar length of stay and similar pain scores at rest following TKA.

Hungry Bone Syndrome due to Primary Parathyroid Adenoma with Multiple Bone Fractures.

Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcemia associated with hypophosphatemia and hypomagnesemia which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. It is a relatively uncommon, but serious adverse effect of parathyroidectomy. The severe hypocalcemia is believed to be due to increased influx of calcium into bone, due to the sudden removal of the effect of high circulating levels of PTH on osteoclastic resorption, leading to a decrease in the activation frequency of new remodeling sites and to a decrease in remodeling space, although there is no good documentation for this. Various risk factors have been suggested for the development of HBS, including older age, weight/volume of the resected parathyroid glands, radiological evidence of bone disease and vitamin D deficiency. The syndrome is reported in 25 to 90% of patients with radiological evidence of hyperparathyroid bone disease vs only 0 to 6% of patients without skeletal involvement. There is insufficient data-based evidence on the best means to treat, minimize or prevent this severe complication of parathyroidectomy. Treatment is aimed at replenishing the severe calcium deficit by using high doses of calcium supplemented by high doses of active metabolites of vitamin D. Preoperative treatment with bisphosphonates has been suggested to reduce postoperative hypocalcemia, but there are to date no prospective studies addressing this issue.