An Analysis on the Effect of Patient-controlled Analgesia Performed by Orthopaedic Department or Postoperative Pain Control after Shoulder and Elbow Surgery

BACKGROUND: We investigated the effectiveness of pain management and the adverse events of intravenous (IV) patient-controlled analgesia (PCA) after orthopedic surgery. METHODS: From September 2014 and August 2015, we performed a retrospective analysis of 77 patients who underwent orthopedic surgery of the shoulder or the elbow in our hospital. The composition of the intravenous PCA administered to the patients was as follows: 250 mg of dexketoprofen trametamol, 70 mg of oxycodone, and 0.6 mg of ramosetron, which were made up to 79 ml of normal saline. We evaluated and statistically analyzed the difference in the visual analogue scale (VAS) scores for pain at immediate postoperation, at 24 hours of PCA, at 72 hours of PCA, and after discontinuation of PCA and in the incidence of adverse events. RESULTS: We found that VAS score decreased for 3 postoperative days and that with discontinuation of IV PCA a meaningful change in VAS score was no longer seen. Of the 77 patients, 22 presented with adverse events (28.6%). We terminated IV PCA temporarily in the 21 patients who presented with adverse events; we terminated analgesia permanently in one patient (1.2%). Consequently, 76 of 77 patients carried out IV PCA till the designated period. CONCLUSIONS: Intravenous PCA after orthopedic surgery of the shoulder or the elbow may be accompanied with adverse events. Careful assessment of the patient and treatment of the adverse outcomes are key to a successful maintenance of PCA and to a successful management of postoperative pain.

An Analysis on the Effect of Patient-controlled Analgesia Performed by Orthopaedic Department or Postoperative Pain Control after Shoulder and Elbow Surgery

BACKGROUND: We investigated the effectiveness of pain management and the adverse events of intravenous (IV) patient-controlled analgesia (PCA) after orthopedic surgery. METHODS: From September 2014 and August 2015, we performed a retrospective analysis of 77 patients who underwent orthopedic surgery of the shoulder or the elbow in our hospital. The composition of the intravenous PCA administered to the patients was as follows: 250 mg of dexketoprofen trametamol, 70 mg of oxycodone, and 0.6 mg of ramosetron, which were made up to 79 ml of normal saline. We evaluated and statistically analyzed the difference in the visual analogue scale (VAS) scores for pain at immediate postoperation, at 24 hours of PCA, at 72 hours of PCA, and after discontinuation of PCA and in the incidence of adverse events. RESULTS: We found that VAS score decreased for 3 postoperative days and that with discontinuation of IV PCA a meaningful change in VAS score was no longer seen. Of the 77 patients, 22 presented with adverse events (28.6%). We terminated IV PCA temporarily in the 21 patients who presented with adverse events; we terminated analgesia permanently in one patient (1.2%). Consequently, 76 of 77 patients carried out IV PCA till the designated period. CONCLUSIONS: Intravenous PCA after orthopedic surgery of the shoulder or the elbow may be accompanied with adverse events. Careful assessment of the patient and treatment of the adverse outcomes are key to a successful maintenance of PCA and to a successful management of postoperative pain.

Ossification of the Ligamentum Flavum

Ossification of the ligamentum flavum is a rare cause of thoracic myelopathy. It develops in East Asians more frequently than in people from other areas. The exact pathophysiology has not been elucidated yet; however, it largely depends on biomechanical alterations, especially changes in the tensile force. Because the spinal cord is compressed from the posterior side, the first and most common clinical manifestation is usually loss of functional gait and spastic paralysis, which develop as the spinal cord compression progresses. The choice of diagnostic imaging is T2 sagittal magnetic resonance imaging scanning. Whole spine scanning is mandatory to identify multiple areas of compression and any associated distal lumbar diseases. Fine computed tomography imaging is necessary to make a differential diagnosis and set up a precise surgical plan. Conservative treatment does not work in this disorder. Decompression surgery is the only option and prognosis after surgical treatment is better with this disorder than with other causes of thoracic myelopathy. The severity of preoperative symptoms and the time interval before surgical treatment are the most important prognostic factors.

Demineralized Bone Matrix, as a Graft Enhancer of Auto-Local Bone in Posterior Lumbar Interbody Fusion

STUDY DESIGN: A case controlled study with prospective data collection. PURPOSE: To evaluate the early influence and the final consequence of demineralized bone matrix (DBM) on auto-local bone as a graft enhancer in posterior lumbar interbody fusion (PLIF). OVERVIEW OF LITERATURE: DBM is known as an osteoinductive material; however, it has not been clearly recognized to enhance auto-local bone with a small amount. METHODS: Patients who had a PLIF were allocated into two groups. Group I (70 cases) used auto-local bone chips and group II (44 cases) used DBM as an additive to auto-local bone, 1 mL per a segment. Group selection was alternated. Early assessment was performed by computed tomography at 6 months and final assessment was done by simple radiography after 24 months at least. The degree of bone formation was assessed by 4 grade scale. RESULTS: The subjects of both groups were homogenous and had similar Oswestry Disability Index at final assessment. The ratio of auto-local bone chips and DBM was 6:1. The degree of bone formation at 6 months after surgery was superior in group II. However, there was no significant difference between the two groups at the final assessment. CONCLUSIONS: DBM was not recognized to enhance auto-local bone with small amount.

The Degree of Bacterial Contamination While Performing Spine Surgery

STUDY DESIGN: Prospective experimental study. PURPOSE: To evaluate bacterial contamination during surgery. OVERVIEW OF LITERATURE: The participants of surgery and ventilation system have been known as the most significant sources of contamination. METHODS: Two pairs of air culture blood agar plate for G(+) bacteria and MacConkey agar plate for G(-) bacteria were placed at 3 different locations in a conventional operation room: in the surgical field, under the airflow of local air conditioner, and pathway to door while performing spine surgeries. One pair of culture plates was retrieved after one hour and the other pair was retrieved after 3 hours. The cultured bacteria were identified and number of colonies was counted. RESULTS: There was no G(-) bacteria identified. G(+) bacteria grew on all 90 air culture blood agar plates. The colony count of one hour group was 14.5+/-5.4 in the surgical field, 11.3+/-6.6 under the local air conditioner, and 13.1+/-8.7 at the pathway to the door. There was no difference among the 3 locations. The colony count of 3 hours group was 46.4+/-19.5, 30.3+/-12.9, and 39.7+/-15.2, respectively. It was more at the surgical field than under the air conditioner (p=0.03). The number of colonies of one hour group was 13.0+/-7.0 and 3 hours group was 38.8+/-17.1. There was positive correlation between the time and the number of colonies (r=0.76, p=0.000). CONCLUSIONS: Conventional operation room was contaminated by G(+) bacteria. The degree of contamination was most high at the surgical field. The number of bacteria increased right proportionally to the time.

The Influence of Postoperative Tibiofemoral Alignment on the Clinical Results of Unicompartmental Knee Arthroplasty

PURPOSE: To evaluate the influence of postoperative tibiofemoral alignment on the clinical results and failure in patients who underwent unicompartmental knee athroplasty (UKA). MATERIALS AND METHODS: We reviewed 246 cases of medial UKA which were followed up for at least 5 years after the operation. The clinical results were compared between 5 groups classified according to the tibiofemoral angle that was measured at 3 months after surgery. We analyzed the relationship between the tibiofemoral alignment and the failure after UKA. RESULTS: The preoperative tibiofemoral angle was changed from 0.4degrees of varus to 5.4degrees of valgus after surgery and the average correction angle was 5.8degrees. During the follow-up, which averaged 7 years and 5 months, the knee score and function score were improved significantly in all groups regardless of the tibiofemoral angle (p0.05). However, there were significant differences in the cumulative survival rate of implants between the groups and the highest rate was found in the group with a tibiofemoral angle of 4degrees to 6degrees of valgus (p<0.01). CONCLUSIONS: The tibiofemoral angle after UKA had no significant influence on the midterm clinical scores, but there was a significant relationship between the postoperative tibiofemoral angle and failure rate of implant.

The Tourniquet Pressure 200 mmHg for Total Knee Arthroplasty: is it possible? / 대한정형외과연구학회지

PURPOSE: To evaluate the possibility of lowering tourniquet pressure to 200 mmHg during total knee arthroplasty (TKA) by pressing the femoral artery. Lowering the toniquette pressure can attribute to minimize the soft tissue damage and pain after the operation. MATERIALS AND METHODS: We analyzed patients who had TKA from Sep 16th, 2010 to Mar 3rd, 2011. Among them, 35 patients (test I) had operations on both knees, and 50 patients (test II) underwent operation on one knee. We excluded the patients who had a previous operation, infection, or bleeding tendency. We put a cotton roll at the antero-medial side of the thigh just under the tourniquet in order to apply more pressure on the femoral artery that is scanned by ultrasonography. We scored 0 on non-bleeding, 1 on bleeding that did not affect the operation, and 2 on bleeding which disturbed the operation. RESULTS: In test I, the group which applied 200 mmHg with local pressure, 24 patients (68.6%) scored 0, 9 patients (25.7%) scored 1, and two patients (5.7%) scored 2. In the other group used pressure 250 mmHg, however, 31 patients (88.6%) scored 0, 4 patients (11.4%) scored 1, and no one scored 2 (p=0.039). Totally, in the 200 mmHg group with local pressure, 33 patients had no problem in surgery, and only for 2 patients (5.7%), we had to increase pressure. For the patients with 250 mmHg, however, we had to increase pressure on nobody (0%). In test II, in the group which had operation on one knee with 200 mmHg with local pressure, 14 patients scored 0, 8 patients scored 1, and one patient scored 2. Also in the 250 mmHg group, 24 patients scored 0, 2 patients scored 1, and one patient scored 2. (p=1.000). Overall results demonstrate no differences in bleeding that disturb operations statistically. CONCLUSION: Even with a little more bleeding compared to the 250 mmHg group, 94.8% of patients can have operation with no bleeding problems by using a cotton roll and the pressure 200 mmHg. For successful operations, there is no difference between groups using 250 mmHg and 200 mmHg with local pressure on femoral artery.

Total Knee Arthroplasty after Failed Unicompartmental Knee Arthroplasty / 대한정형외과학회잡지

PURPOSE: To identify the causes of failure after unicompartmental knee arthroplasty (UKA), and to evaluate considerations for surgical procedures and the results of revision total knee arthroplasty (TKA) performed after failure of UKA. MATERIALS AND METHODS: Eight hundreds and fifty-two cases of UKA were performed from January 2002 to June 2011. Forty-seven cases of failures after UKA were analyzed for the cause of the failures, and thirty-five cases of revision TKA after failure were analyzed for the operative findings and surgical technique. The clinical results were measured for thirty cases which were followed-up on at least two years after TKA. The mean duration of follow-up was four years and one month after revision TKA and the mean patient age at the time of surgery was sixty-five years. RESULTS: For the cause of failures after UKA, there were twenty-two cases of early loosening of prosthesis, seventeen cases of simple mobile bearing dislocation, five cases of infection, one case of fracture of medial tibial condyle and two cases of unknown origin pain. In operative findings of thirty-five cases of TKA after failed UKA, there were twenty-seven cases of bone defect requiring treatment and the mean thickness of the defect was 10.6 mm. For the treatment of bone defect, there were five cases of autogenous bone graft, twenty-one cases of metal blocks, and one case of autogenous bone graft with metal block. The stem was used in tibial implants for nineteen cases, and one case of use in tibial and femoral implants. For thirty cases where follow-ups were possible at least two years after operation, the mean knee score was improved from 68.2 to 85.2 and the mean knee function score was improved from 67.7 to 78.0 at the last follow-up, respectively. The mean range of knee motion was 107.2degrees pre-operatively, which was recovered to 120.7degrees after the operation. The mean tibiofemoral angle was changed from 1.7degrees of valgus to 5.2degrees of valgus. CONCLUSION: As shown in this study, the tibial bone defect was the most important problem in revision TKA after failure of UKA. Therefore, proper indication and accurate surgical technique using autogenous bone graft, metal block and stemmed implants would be able to achieve satisfactory results in revision TKA after failure of UKA.

The Oblique Proximal Interlocking Screw for Intramedullary Nailing Proximal Tibial Fractures: Is It Safe? / 대한정형외과학회잡지

PURPOSE: We tried to reveal radiographic clues for the possibility of damages to the important structures, including the peroneal nerve and the anterior tibial artery, caused by a proximal interlocking screw with a medial to lateral oblique direction (ObML-PIS). MATERIALS AND METHODS: The length of the proximal tibiofiular joint (PTFJ) was measured from the tip of the fibular head to the end of PTFJ on the simple oblique radiographs of 22 cases of tibial intramedullary (IM) nailing. The center (O) of the IM nailing, from the tibial anterior cortex at the level of insertion of an ObML-PIS, was measured on the simple lateral radiographs. The angle POA (P: a point 10 mm anterior from the anterior fibular border, A: a point on the tangent line from the O point to the posteromedial cortex of the fibula) was measured on the MR axial view of 60 cases, and within this angle an ObML-PIS could injure the important anatomical structures. Transverse and 45-degree oblique diameters of the proximal tibia on the MR axial view were also measured. RESULTS: The PTFJ length was 18.5+/-3.3 mm and the O point was located at 15.3+/-3.4 mm posterior from the tibial anterior cortex. The angle POA was 21.4+/-6.2-67.8+/-6.7 degrees with medial to lateral oblique directions. The transverse diameter of the proximal tibia was 58.0+/-5.8 mm and the 45-degree oblique diameter was 50.7+/-6.2 mm. CONCLUSION: Special caution may be needed when we use an ObML-PIS because it is located at the level distal from the end of the PTFJ and within the POA angle, and the peroneal nerve and anterior tibial artery can possibly be severed.