Improving postoperative analgesia in hallux valgus surgery: oral opioids suppression by addition of a single transdermal fentanyl patch: a prospective evaluation.

The last decade there is an exponential increase in opioid related deaths. This is proven to be correlated with the rising medical prescription rates of strong opioids. We investigated whether pain after hallux valgus surgery under popliteal nerve block could be adequately controlled without the prescription of oral opioids, with a single transdermal fentanyl patch. In this prospective observational study with 100 patients undergoing corrective first metatarsal osteotomies we prospectively investigated the adverse effects and need for extra pain medication. The transdermal fentanyl patch was applied one hour before surgery, prior to the ultrasound guided popliteal nerve block. Patients filled out a questionnaire every 6 hours to evaluate the pain [VAS-score], nausea [PONV-score], activity [acivity and ambulation score] and the intake of extra medication. Postoperative pain was well controlled [Mean VAS 2,53]. The maximum mean VAS score [3.93] was recorded 36 hours postoperatively. 63.8% of patients had less pain than expected. No major adverse effects were reported by the patients. Nausea was mainly mild and the majority of patients reported 'no effect' or 'sometimes' effect on daily activities. In an era where surgeons need to be aware of the threat of overuse of strong opioids, the use of a single transdermal fentanyl patch in combination with an ultrasound guided nerve block can be a good alternative in hallux valgus surgery. The use of the patch seems to obviate the need for oral opioids after discharge. Nausea and vomiting were a concern - as expected -, but only at 24 and 36 hours. On the other hand nausea did not seem to affect activity, as there was a gradual increase in activity score over time.

Screwless scarf osteotomy for hallux valgus: Evaluation of radiologic correction.

BACKGROUND: The scarf osteotomy is a standard procedure to correct hallux valgus. Recent modifications in the technique allow for important translations of the bone fragments without the need for screw fixation. We performed the first prospective analysis of radiographic parameters after a screwless scarf osteotomy. Prospective study of pre- and postoperative standing radiographs of the feet let us quantify angle reduction and shortening, lengthening or lowering of the first metatarsal. METHODS: 100 patients undergoing a screwless scarf osteotomy were evaluated radiographically before and after surgery. The 1-2 IM angle, HVA, length of the first metatarsal, protrusion length and height of the first metatarsal head were measured. RESULTS: The mean 1-2 IM angle was reduced significantly, to a normal range. The mean reduction of the first metatarsal length and protrusion length was 0.3 and 0.14cm respectively. The metatarsal head was lowered 0.3cm on average. CONCLUSIONS: A minimal mean reduction of the first metatarsal length was observed, but it is possible to lengthen the first metatarsal if necessary. In 23% of cases, an increase of protrusion length was obtained. The screwless scarf osteotomy results in a good correction of the 1-2 IM angle and HVA. If necessary, plantarisation of the first metatarsal head could be obtained. Secondary displacement was seen in 1 patient. LEVEL OF EVIDENCE: IIa, prospective controlled trial.

Partial resection of the PCL insertion site during tibial preparation in cruciate-retaining TKA.

PURPOSE: Based on the anatomy of the tibial PCL insertion site, we hypothesized that at least part of it is damaged while performing a standard tibial cut in a PCL-retaining total knee replacement. The purpose of this study was to determine and quantify the amount of resection of the tibial PCL attachment with a 9 mm tibial cut with 3 degrees of posterior slope. METHODS: Twenty cadaver tibias were used. The borders of the PCL footprint were demarcated, and calibrated digital pictures were taken in order to determine the surface area. A standard tibial intramedullary guide was used to prepare and perform a tibial cut at a depth of 9 mm with 3 degrees posterior slope. After the tibial cut was made, a second digital picture was taken using the same methodology to measure the surface area of the remaining PCL insertion. RESULTS: The mean surface area of the intact tibial PCL footprint before the cut was 148.9 ± 25.8 mm(2) and after the tibial cut 47.1 ± 28.0 mm(2). On average, 68.8 ± 15.3 % of the surface area of the PCL insertion was removed. CONCLUSION: The results of this study, therefore, indicate that the conventional technique for tibial preparation in cruciate-retaining total knee arthroplasty can result in damage or removal of a significant part of the tibial PCL insertion.

The effect of Luque-Galveston fusion on curve, respiratory function and quality of life in Duchenne muscular dystrophy.

The aim of this retrospective study was to evaluate the long-term effect of the Luque-Galveston spinal fusion in Duchenne muscular dystrophy (DMD) patients. Twenty patients had undergone this operation at a mean age of 153 years (surgical group, A). The correction of their scoliosis amounted to +/- 55.8%, after an average follow-up period of 3 years. This is in accordance with the literature. The authors would therefore advise to perform spinal fusion in an early stage of the disease, once a rapid evolution of the scoliosis is seen. The decline of respiratory function slightly diminished after surgery, but not significantly. This means that no expectations should be made to improve respiratory function, as respiratory function decline continues relentlessly. Most authors agree with this statement. Patient satisfaction after surgery was relatively high, mainly because of an improved sitting balance, but only 60% of the questionnaires were available. Twenty-five other patients were not operated upon (non-surgical group, B). They had better results at ages 153 and 183, but this was mainly due to the fact that group B contained more benign cases according to the Oda classification.

Revision of a tibial baseplate using a customized oxinium component in a case of suspected metal allergy. A case report.

Materials currently used for total knee arthroplasty (TKA) are well known for their good biocompatibility, but corrosion of the implant and metal ion release may elicit an immune response in the periprosthetic tissue. Its role in the outcome of the implant remains a subject of discussion. Metal sensitivity after joint replacement is frequent, but few patients exhibit symptoms. Nickel, cobalt and chromium are the most common sensitizers, but allergic reactions to titanium and vanadium have also been described. We present a case of a 46-year old woman with persistent dermatitis following TKA revision with an oxidized zirconium (oxinium) femoral component and Ti6Al4V tibial baseplate. After revision with a customized oxinium tibial component, symptoms resolved completely.

Traumatic talus extrusion: case reports and literature review.

Total talar dislocation is a rare injury, which is usually open and with associated fractures. We report two cases of open anterolateral talar extrusions following high-energy traffic accidents. Both were treated with wound debridement, joint irrigation, closed reduction and external fixation. At 12 months follow-up, both patients had pain-free motion of the ankle without any signs of avascular necrosis or arthritis.