Periarticular cocktail injection is more useful than nerve blocks for pain management after anterior cruciate ligament reconstruction.

Background: Anterior cruciate ligament (ACL) reconstruction is commonly associated with moderate-to-severe postoperative pain. Notably, various pain control strategies, a femoral nerve block (FNB) with a lateral femoral cutaneous nerve block (LFCNB), adductor canal block (ACB) with LFCNB, or periarticular cocktail injection (PI), have been investigated. However, no studies compare the effects of FNB with LFCNB, ACB with LFCNB, and PI for pain control after ACL reconstruction. This study aimed to evaluate the impact of FNB with LFCNB, ACB with LFCNB, and PI for pain relief in the early postoperative period after ACL reconstruction. Methods: This retrospective controlled clinical trial enrolled 299 patients who underwent primary ACL reconstruction at our hospital between April 2016 and October 2022. We categorized these cases into groups based on the use of PI (PI group), FNB with LFCNB (FNB group), and ACB with LFCNB (ACB group) for pain management. We selected 40 cases each, with matched age, sex, and body mass index (BMI) from each group, resulting in 120 cases for analysis. In the FNB and ACB groups, 0.75% ropivacaine 15 ml was injected under ultrasound guidance preoperatively. In the PI group, a mixture of 0.75% ropivacaine 20 ml, normal saline 20 ml, and dexamethasone 6.6 mg was injected half at the start of surgery and the rest just before wound closure. Patient demographics (age, sex, height, body weight, and BMI) and surgical data (the requirement for meniscal repair, operative time, and tourniquet inflation time) were analyzed. After ACL reconstruction, patients' numerical rating scale pain scores (NRS) (0-10) were recorded at 30 min and 4, 8, 12, 24, 48, and 72 h postoperatively. NRS were then compared among the three groups using analysis of variance. In addition, within each group, these data were compared between the NRS ≥7 and NRS ≤6 groups using a t-test. Results: There were no significant differences in patient demographics and surgical data. Pain scores were significantly higher in the PI group than in the FCB and ACB groups 30 min postoperatively, but they were lower at 12, 24, 48, and 72 h postoperatively. In the FNB group, there were no significant differences in the demographic and surgical data by NRS pain score. In the ACB group, the number of men was significantly higher in the NRS ≥7 group than in the NRS ≤6 group (p = 0.015). In the PI group, tourniquet inflation time was significantly longer in the NRS ≥7 group than in the NRS ≤6 group (p = 0.008). Conclusions: Following ACL reconstruction using a hamstring autograft, periarticular cocktail significantly reduced early postoperative pain compared with nerve block combinations.

Limited preoperative knee extension in anterior cruciate ligament reconstruction using a hamstring tendon affects improvement of postoperative knee extensor strength.

PURPOSE: This study aimed to determine the factors affecting knee extensor strength 6 months after anterior cruciate ligament (ACL) reconstruction using autograft hamstring tendon. METHODS: 144 patients who could undergo regular follow-up after ACL reconstruction were divided into 2 groups: those with greater than 90% (Group A: n = 95) and less than 85% (Group B: n = 49) isokinetic knee contraction at 60°/s 6 months post-ACL reconstruction. Basic information, injury status, limited preoperative knee extension, and knee extensor strength at 3 and 6 months postoperatively were compared between the groups. Multivariate logistic analysis was performed and included variables that showed statistically significant differences between the groups in the univariate analysis. In addition, the cut-off value for the limb symmetry index (LSI) at 3 months postoperatively needed to exceed an LSI of 90% at 6 months postoperatively was calculated using the receiver operating characteristics curve. RESULTS: Age, preoperative waiting period, limited preoperative knee extension, and knee extensor strength at 3 months postoperatively were significantly different between the two groups. The multivariate logistic analysis showed that all the variables affected the improvement in knee extensor strength at 6 months postoperatively. Limited preoperative knee extension was the most significant factor (odds ratio: 15.1, 95% confidence interval: 2.57-118.56, p < 0.01). The LSI cut-off value at 3 months postoperatively was 72.0%. CONCLUSION: Key factors in achieving the necessary knee extensor strength criteria for return to sports at 6 months post-ACL reconstruction include addressing limited preoperative knee extension and achieving an LSI ≥ 72% in knee extensor strength at 3 months postoperatively. LEVEL OF EVIDENCE: Level III.

Anesthetic management in a child with Rolland-Desbuquois type dyssegmental dysplasia.

A case of a 17-month-old boy with dissegmental dysplasia of the Rolland-Desbuquois type, who was scheduled for bilateral inguinal herniotomy, is presented. Preoperative assessment showed limited mouth opening, head extension, and kyphosis. Intubation with a size 4 mm endotracheal tube (ETT) was achieved with fiberoptic bronchoscopy, after which surgery proceeded uneventfully and the ETT was carefully removed. Copious airway secretions required frequent suctioning. On the second postoperative day, respiratory status stabilized, and the patient was discharged home.

Cryoglobulinemia (review).

Cryoglobulins are immunoglobulins that precipitate at low temperatures and redissolve upon rewarming. Cryoglobulinemia refers to the presence of circulating cryoglobulins in serum, and generally leads to a systemic inflammatory syndrome characterized by fatigue, arthralgia, purpura, neuropathy and glomerulonephritis. The disease mainly involves small to medium-sized blood vessels and causes vasculitis due to cryoglobulin-containing immune complexes. Cryoglobulinemia is classified into three types (I, II and III) on the basis of immunoglobulin composition. Predisposing conditions include lymphoproliferative disease, collagen disease and hepatitis C virus (HCV) infection. The diagnosis of cryoglobulinemic syndrome is predominantly based on the laboratory demonstration of serum cryoglobulins. Treatment is often directed towards the underlying disease state. For patients with chronic HCV infection, anti-viral therapy is indicated. Intense immunosuppressive or immunomodulatory therapy, including steroids, plasmapheresis and cytotoxic agents, is reserved for organ-threatening or recalcitrant disease. In this review, we discuss the clinical characteristics of the three types of cryoglobulinemia.