A neuro-anatomically grounded scheme for LIA gives superior analgesia and comfort levels compared to epidural analgesia until seven days after total knee arthroplasty.

LIA is an emerging alternative for patient-con- trolled epidural analgesia(PCEA) after total knee arthroplasty(TKA). LIA allows faster mobilisation, eliminates the risks of epidural catheters, and can hasten patient turnover. Conversely, PCEA provides reliable pain relief in the first days after this type of surgery. The purpose of this study was to evaluate the quality of antinociception, postoperative nausea & vomiting (PONV), and general comfort until 7 days postoperatively. 40 patients received PCEA and 41 received LIA. Patients were retrospectively asked for pain scores at the day of surgery(=D0), D2, and D7, PONV, and general comfort scores. Patients in the LIA group reported equal pain scores at D0, significantly better PONV scores and pain scores at D2 and D7. In addition to faster mobilisation and elimination of the risks and burden of an epidural catheter and PCEA, LIA delivers equal to better analgesia, and better PONV and general comfort scores.

Midterm results of comprehensive surgical reconstruction including sulcus-deepening trochleoplasty in recurrent patellar dislocations with high-grade trochlear dysplasia.

BACKGROUND: Trochlear dysplasia is one of the most consistent anatomic factors that can lead to recurrent patellar dislocations. Various trochleoplasty procedures have been described to treat patellar dislocations in high-grade dysplasia by creating a new congruent trochlea. PURPOSE: To present the midterm efficacy and outcome of the sulcus-deepening trochleoplasty procedure in patients with recurrent patellar dislocations due to high-grade trochlear dysplasia. The clinical evaluation results, the amount of radiological correction, and the prevalence of arthritis were recorded. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 27 skeletally mature patients (31 knees) with recurrent patellar dislocations due to high-grade trochlear dysplasia without any previous surgery were retrospectively included from September 1993 to September 2006. All patients underwent sulcus-deepening trochleoplasty combined with a bony and/or soft tissue procedure according to concomitant etiological factors to patellar dislocations: medial patellofemoral ligament reconstruction (16.1%), vastus medialis obliquus plasty (83.8%), tibial tuberosity distalization (51.6%), tibial tuberosity medialization (67.7%), and lateral retinaculum release (67.6%). Mean follow-up was 7 years (range, 2-9 years). RESULTS: The mean sulcus angle decreased significantly (P < .01) from 152° ± 16° preoperatively to 141° ± 9° postoperatively, tibial tuberosity-trochlear groove distance decreased significantly (P < .001) from 19 ± 4 mm to 12 ± 5 mm, and patellar tilt decreased significantly (P < .001) from 37° ± 7° to 15° ± 8°. No recurrence was observed, and there was no case of stiffness. Apprehension signs remained positive in 19.3% of the cases, patellar tracking was normal in all cases, and the lateral patellar glide test finding was negative in 96.8%. The mean preoperative International Knee Documentation Committee (IKDC) score was 51 (range, 25-80), and the mean postoperative IKDC score was 82 (range, 40-100) (P < .001), while the mean Kujala score improved from a preoperative 59 (range, 28-81) to 87 (range, 49-100) postoperatively (P < .001). There was no radiographic evidence of patellofemoral arthritis at the latest follow-up. CONCLUSION: Sulcus-deepening trochleoplasty is a valid option for the primary surgical treatment of carefully selected patients with recurrent patellar dislocations with high-grade trochlear dysplasia type B and D. Concomitant etiological factors must be cautiously corrected in an associated procedure. Midterm follow-up showed satisfactory restoration of patellar stability and improvement of knee scores with no complication of subsequent arthritis.

The Lyon's sulcus-deepening trochleoplasty in previous unsuccessful patellofemoral surgery.

PURPOSE: Trochleoplasty is a relatively rare operation with few published results and it remains a technically demanding procedure which requires careful patient selection. The ideal candidate for surgery remains to be elucidated, and some authors consider it as a good revision option in cases of previous unsuccessful operations for persisting patellar dislocation with underlying trochlear dysplasia. The purpose of this study is to record the results from the application of sulcus-deepening trochleoplasty in patients with trochlear dysplasia and previous unsuccessful surgery for patellar dislocation. METHODS: Twenty-two patients (24 knees) were operated upon during the period 9/1993-9/2006; they had undergone surgery for patellofemoral instability and had persistent patellar dislocation, and were followed-up for a mean of 66 months (24-191). Trochleoplasty was performed in all patients using the same technique and rehabilitation protocol. Additional soft-tissue and bony operations were performed in every case. RESULTS: Of all cases, 29.1% had type B and 70.9% had type D trochlear dysplasia. After trochleoplasty, no patient had a patellar re-dislocation up to the last follow-up. Pain decreased in 72% and the apprehension sign was negative in 75% of the cases (p < 0.01). Sulcus angle decreased from 153° ± 14° to 141° ± 10° (p < 0.01), TT-TG distance decreased from 16 ± 6 mm to 12 ± 2 mm (p < 0.001), and patellar tilt decreased from 31° ± 14° to 11° ± 8° (p < 0.0001). Mean pre-operative Kujala score was 44 (25-73) and at the latest follow-up it increased to 81 (53-100), (p < 0.001). At the time of final follow-up, there was no case of patellofemoral arthritis. CONCLUSIONS: Trochlear dysplasia is a key factor in the treatment of recurrent patellar dislocation and its correction could be included in the surgical options. Sulcus-deepening trochleoplasty is an acceptable revision option for the surgical treatment of patients with persisting patellar dislocation and high-grade trochlear dysplasia.

Intramedullary fixation of intertrochanteric hip fractures: a comparison of two implant designs. A prospective randomised clinical trial.

We report the results of a prospective randomized clinical trial comparing the Gamma 3 nail with the ACE trochanteric nail for the treatment of pertrochanteric femoral fractures. One hundred and twelve consecutive patients were enrolled in the study: 61 patients were treated with the Gamma 3 nail, 51 with the ACE trochanteric nail. The two groups were matched for age, fracture type and preoperative Merle d'Aubigné hip score. All patients were followed up clinically and radiographically on a regular basis between 6 weeks and one year postoperatively. Twenty-six patients (23%) died within the first postoperative year. Six patients were lost to follow-up. In each group, two patients were revised due to mechanical failure. Nonunion did not occur. The mean postoperative hip scores in the Gamma 3 and the ACE group were 14.19 and 14.12 respectively, with no significant difference (p = 0.92). Walking ability was adequately restored in approximately 80% of the patients. Both implants appeared as safe and effective methods of treatment for intertrochanteric hip fractures.