Adjuvant dexamethasone for bupivacaine sciatic and ankle blocks: results from 2 randomized placebo-controlled trials.

BACKGROUND AND OBJECTIVES: Dexamethasone as a local anesthetic adjuvant has been shown to prolong the time to first postoperative pain and improve postoperative analgesia following upper-limb brachial plexus block. However, the lack of systemically administered dexamethasone in controls makes interpretation of previous studies difficult. We performed 2 prospective, randomized, double-blind, placebo-controlled trials to test whether the addition of dexamethasone 8 mg to bupivacaine for sciatic and ankle blocks prolongs block duration, improving postoperative analgesia. METHODS: One hundred twenty-six patients presenting for elective foot/ankle surgery under sciatic (n = 66) or ankle blocks (n = 60) received 30 mL bupivacaine 0.5% + dexamethasone 8 mg or saline 2 mL. Alternate solutions were administered by intramuscular injection into the ipsilateral thigh. Outcomes assessed at 24 and 48 hours included pain onset, numerically rated pain, and supplementary tramadol consumption. RESULTS: For the sciatic study, fewer dexamethasone group patients experienced pain at 24 hours (13% vs 47%, P = 0.01), an effect supported by multiple post hoc analyses for pain from 20 to 34 hours. No benefit existed at 48 hours or at any time for the ankle block. For each study, pain-free survival curves for the first 48 hours were not significantly different between groups. Pooled analysis of the 2 individual studies further supported the absence of a significant dexamethasone effect: hazard ratio (0.81; 95% confidence interval, 0.58-1.53; P = 0.94). For both studies, there were no differences between groups for all other study outcomes including worst and average pain, the requirement for tramadol, and patient satisfaction. CONCLUSIONS: Substitution of systemic dexamethasone for perineural dexamethasone during bupivacaine sciatic and ankle blocks had only a minor analgesic enhancing effect. Given recent animal studies showing dexamethasone neurotoxicity, the perineural route for dexamethasone administration requires reevaluation.

Low-volume ultrasound-guided nerve block provides inferior postoperative analgesia compared to a higher-volume landmark technique.

BACKGROUND AND OBJECTIVES: Ultrasound guidance reduces the required local anesthetic volume for successful peripheral nerve blockade, but it is unclear whether this impacts postoperative analgesia. This prospective, randomized, observer-blinded study tested the hypothesis that a low-volume ultrasound-guided ankle block would provide similar analgesia after foot surgery compared with a conventional-volume surface landmark technique. METHODS: A total of 72 patients presenting for elective foot surgery under general anesthesia were randomized to receive a low-volume ultrasound-guided ankle block (n = 37; ropivacaine 0.5% adjacent the anterior/posterior tibial arteries and short saphenous vein; subcutaneous infiltration around the saphenous and superficial peroneal nerves) or conventional-volume surface landmark guided technique (n = 35; 30 mL of ropivacaine 0.5%). Patients received regular postoperative acetaminophen, diclofenac, and rescue tramadol. Assessment was in the recovery room and at 24 hours for pain and tramadol consumption. RESULTS: Mean (SD) total local anesthetic volume for the low-volume ultrasound group was 16 (2.1) mL. Block success in the recovery room was similar between groups (low-volume ultrasound 89% versus conventional-volume landmark 80%, P = 0.34; however, during the first 24 hours, numerically rated (0-10) "average pain" (median [10-90th percentiles] = 1 [0-4] versus 0 [0-2], P = 0.01), worst pain at rest (1 [0-6] versus 0 [0-2], P = 0.03), and the proportion of patients requiring rescue tramadol (% [95% confidence interval]: 50 [34-46] versus 20 [10-36], P = 0.01) were higher in the low-volume ultrasound group. Numerically rated numbness, weakness, satisfaction, and procedural time were similar between groups. CONCLUSIONS: Low-volume ultrasound-guided ankle block is associated with a high block success rate after foot surgery; however, compared with a conventional volume (surface landmark) technique, the reduced local anesthetic volume marginally compromises postoperative analgesia during the first 24 hours.

Dental service in 2008 Summer Olympic Games.

OBJECTIVE: How to organise an appropriate team to provide quality dental care during the Olympic Games has become an important consideration for each successive host country. The aims of this study were to document dental services provided at the Olympic Games and to provide data for planning future events. SET-UP OF THE DENTAL CARE DEPARTMENT: There were six dental chairs in six independent treatment rooms, one technical laboratory, a sterilising room and an x-ray room equipped with one digital panoramic screening machine and one intraoral x-ray machine in the polyclinic in the Olympic Village in Beijing. Shifts comprised 80 dentists and 28 nurses who were organised into three shifts working from 08:00 until 23:00. RESULTS: In the 2008 Olympic Games, there were 1607 cases involving 1126 patients requiring dental care: 795 cases from 516 athletes; 483 cases from 370 coaches and other staff; and 99 cases from volunteers. Endodontic treatments, permanent fillings, oral hygiene, mouthguards and treatment of pericoronitis were the most frequent procedures in dental care. The Mouthguard Service was extremely popular and well utilised. 122 athletes received new custom-made mouthguards in Beijing. CONCLUSIONS: As the utilisation of the dental service grows, and the burden of providing care for such a large cohort increases, a well-organised dental team becomes increasingly important. More general-practice dentists were needed in the team. Different kinds of specialist were suggested for working in the team-for example, oral and maxillofacial surgeons, sport dentists for mouthguards and endodontists.

The mid-term results of a dual offset uncemented stem for total hip arthroplasty.

The Synergy stem is a third-generation proximal in-growth, tapered titanium alloy uncemented stem, with standard and high offset versions. Two hundred ten primary hip arthroplasties were performed using the Synergy stem in 193 patients. There were 124 males and 69 females with an average age of 58 years (range, 22-85 years). The average follow-up was 75 months (range, 60-96 years). Only 1 stem has required revision, for a stem survival rate of 99.5%. The overall incidence of thigh pain was 2.8%. Intraoperative undisplaced fractures of the proximal femur occurred in 3.3% of patients and were managed at the time with wiring, with no effect on outcome. Minor osteolysis was seen proximally in 10% of patients, but no osteolysis was seen distal to the porous coating.