Consenso SECOT-GEDOS sobre el control del dolor prequirúrgico en artrosis de rodilla y cadera / SECOT-GEDOS consensus on pre-surgical pain management in knee and hip arthrosis

Objetivo: Desarrollar recomendaciones basadas en la mejor evidencia y experiencia sobre el manejo del dolor en pacientes con artrosis de rodilla o cadera e indicación de artroplastia. Métodos: Las recomendaciones se emitieron siguiendo la metodología de grupos nominales. Se seleccionó un grupo director de expertos (5 traumatólogos y un anestesiólogo) que definieron el alcance, usuarios, apartados del documento, posibles recomendaciones, revisiones sistemáticas y se asignaron tareas. Se realizaron 3 revisiones sistemáticas sobre: la eficacia y seguridad de la analgesia prequirúrgica en relación al dolor posquirúrgico; la eficacia y seguridad de la analgesia preventiva, y sobre los factores prequirúrgicos que influyen en el dolor posquirúrgico. Los expertos redactaron los apartados y generaron las recomendaciones correspondientes. El nivel de evidencia y grado de recomendación se clasificaron según el modelo del Center for Evidence Based Medicine de Oxford y el grado de acuerdo por técnica Delphi (2 rondas). El Delphi se amplió a 39 traumatólogos y anestesiólogos. El documento completo circuló entre el grupo director para su última revisión. Resultados: Se generaron 21 recomendaciones. Incluye el manejo farmacológico específico, la evaluación y monitorización de estos pacientes que están en tratamiento, y el tratamiento preventivo del dolor posquirúrgico. Existió consenso mayor del 70% en 19 de ellas. Conclusiones: En el paciente pendiente de artroplastia de cadera o rodilla se debe hacer una correcta evaluación, seguimiento y manejo farmacológico y no farmacológico de los factores que predicen un mal resultado de la intervención, en particular del dolor prequirúrgico. Estas actuaciones pueden mejorar el dolor posquirúrgico y el resultado de la artroplastia (AU)

Objective: To develop recommendations, based on best evidence and experience, on pain management in patients undertaking total knee or hip replacement. Methods: Nominal group methodology was followed. A group of experts was selected (5 orthopedics, 1 anesthesiologist), who defined the scope, users, topics, preliminary recommendations, and 3 systematic reviews: efficacy and safety of pre-surgical analgesia regarding to post-surgical pain, efficacy and safety of pre-emptive analgesia and pre-operative factors of post-operative pain. The level of evidence and grade of recommendation was established using the Oxford Centre for Evidence Based Medicine, and the level of agreement with the Delphi technique (2 rounds). The Delphi was extended to 39 orthopedics and anesthesiologists. The whole document was reviewed by all the experts. Results: A total of 21 recommendations were produced. They include specific pharmacological treatment, as well as the evaluation and monitoring of patients on this treatment, and post-operative pre-emptive treatment. Agreement above 70% was reached in 19 recommendations. Conclusions: In patients undergoing total knee or hip replacement, a proper evaluation, follow-up, pharmacological and non-pharmacological treatment of predictors of poor surgical outcomes should be performed, especially those related to pre-operative pain. This can improve post-operative pain and surgery outcomes (AU)

Analgesia preventiva en artroplastia de cadera o rodilla: una revisión sistemática / Preventive analgesia in hip or knee arthroplasty: a systematic review

Objetivo: Analizar la eficacia y la seguridad de la analgesia preventiva en pacientes que son sometidos a artroplastia de cadera o rodilla por artrosis. Métodos: Se realizó una revisión sistemática: se definió una estrategia de búsqueda bibliográfica sensible en Medline, Embase y Cochrane Library hasta mayo de 2013; se definió la población con los siguientes criterios: pacientes con indicación de artroplastia de cadera y/o rodilla, adultos, dolor moderado a intenso (≥ 4 en la Escala Visual Analógica), la intervención, el uso (eficacia y seguridad) del tratamiento farmacológico (preventivo) próximo a la cirugía. Se incluyeron formulaciones orales, tópicas y parches. Se incluyeron revisiones sistemáticas, metaanálisis, ensayos clínicos y estudios observacionales. Resultados: Se incluyeron 36 artículos de calidad moderada. Incluían pacientes representativos de aquellos a los que se les indica una artroplastia de cadera o rodilla en nuestro país, adultos, con una edad media superior a 50 años, ligera mayor proporción de mujeres y que presentan dolor de moderado a grave (≥ 4 en la Escala Visual Analógica). El dolor posquirúrgico se evaluó sobre todo con la Escala Visual Analógica. Existe mucha variabilidad en cuanto a los fármacos utilizados incluyendo paracetamol, AINE clásicos, AINE selectivos de la Cox-2, opioides, corticoides, antidepresivos, analgésicos para el tratamiento del dolor neuropático y otros como sulfato magnésico, ketamina, nimodipino o clonidina. Todos en general parecen mejorar el dolor posquirúrgico sin presentar acontecimientos adversos graves. Conclusiones: El uso de uno o varios analgésicos en el preoperatorio disminuye el consumo de analgésicos y el dolor en el posoperatorio, al menos el dolor agudo (AU)

Objective: To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis. Methods: A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (≥ 4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected. Results: A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age > 50 years, higher number of women, and reporting moderate to severe pain (≥ 4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events. Conclusions: The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain (AU)

Preventive analgesia in hip or knee arthroplasty: a systematic review.

OBJECTIVE: To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis. METHODS: A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected. RESULTS: A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age >50 years, higher number of women, and reporting moderate to severe pain (≥4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events. CONCLUSIONS: The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain.

SECOT-GEDOS consensus on pre-surgical pain management in knee and hip arthrosis.

OBJECTIVE: To develop recommendations, based on best evidence and experience, on pain management in patients undertaking total knee or hip replacement. METHODS: Nominal group methodology was followed. A group of experts was selected (5 orthopedics, 1 anesthesiologist), who defined the scope, users, topics, preliminary recommendations, and 3 systematic reviews: efficacy and safety of pre-surgical analgesia regarding to post-surgical pain, efficacy and safety of pre-emptive analgesia and pre-operative factors of post-operative pain. The level of evidence and grade of recommendation was established using the Oxford Centre for Evidence Based Medicine, and the level of agreement with the Delphi technique (2 rounds). The Delphi was extended to 39 orthopedics and anesthesiologists. The whole document was reviewed by all the experts. RESULTS: A total of 21 recommendations were produced. They include specific pharmacological treatment, as well as the evaluation and monitoring of patients on this treatment, and post-operative pre-emptive treatment. Agreement above 70% was reached in 19 recommendations. CONCLUSIONS: In patients undergoing total knee or hip replacement, a proper evaluation, follow-up, pharmacological and non-pharmacological treatment of predictors of poor surgical outcomes should be performed, especially those related to pre-operative pain. This can improve post-operative pain and surgery outcomes.

Early postoperative transtibial articular fistula formation after anterior cruciate ligament reconstruction: a review of three cases.

INTRODUCTION: This is a retrospective case report of three cases with an early postoperative transtibial fistula after anterior cruciate ligament reconstruction (ACL). MATERIALS AND METHODS: The patients had undergone ACL reconstruction and complained of fluid drainage through the not-healed wound or swelling localized on the anteromedial aspect of the ipsilateral proximal tibia during the early postoperative. Magnetic resonance imaging showed a multilocular fluid-filled cyst arising from the distal hole of the tibial bone tunnel. Open resection of the fistula and the cyst was performed in all cases and communication between the tibial tunnel and the joint space was confirmed. During revision surgery the distal hole of the tibial tunnel was covered with a fascio-periosteal flap. RESULTS: All wounds healed without complications. There was no recurrence of drainage or cyst formation. At 2 years follow-up the knee function was normal and was not affected by the complication in any of the patients. Early postoperative transtibial fistulae after ACL reconstruction are rare complications that clinically present either as anterior tibial cysts or persistent wound drainage. Surgical treatment is required, and some delay in the rehabilitation routine is required, but the final outcome is not affected.

Las nuevas guías de profilaxis de enfermedad tromboembólica venosa en artroplastia de cadera y rodilla electivas / The new guidelines for deep venous thromboembolic disease prophylaxis in elective hip and knee replacement surgery. Are we nearer or further away from a consensus?

La profilaxis de eventos tromboembólicos venosos (ETV) tras artroplastia electiva de cadera o rodilla es un tema controvertido. Recientemente, 3 guías clínicas sobre este tema (las guías NICE, ACCP y AAOS) han sido actualizadas. Las guías presentan puntos en común: es necesario de hacer profilaxis; es recomendable asociar profilaxis mecánica y farmacológica en los pacientes que han sufrido un ETV previo; las medidas mecánicas aisladas son efectivas y las heparinas de bajo peso molecular, los nuevos anticoagulantes orales y el fondaparinux son fármacos eficaces. Hay cierto consenso en recomendar la anestesia regional, en desaconsejar estudios ecográficos en pacientes asintomáticos y en promover la movilización precoz del paciente. Hay discrepancias sobre la terapia farmacológica más adecuada y, el momento de inicio y duración de esta, sobre los filtros de vena cava, los antiagregantes y los factores de riesgo de ETV o sangrado (AU)

Venous thromboembolism events (VTE) prophylaxis after elective hip or knee replacement surgery is a subject of controversy. Three sets of guidelines (NICE, ACCP and AAOS) on this topic have recently been updated. The guidelines have points in common: prophylaxis is necessary, it is recommended to combine mechanical and pharmacological prophylaxis in patients who have suffered a previous VTE, isolated mechanical measures and low molecular weight heparins are effective, the new oral anticoagulants and fondaparinux are effective drugs. There is some consensus in recommending regional anaesthesia, in advising against echography studies in asymptomatic patients, and in the promotion of early mobilisation of the patient. There is controversy over the most suitable pharmacological treatment and the time of starting, and the duration of this, as well as on vena cava filters, antiplatelet drugs, and VTE or bleeding risk factors (AU)

[The new guidelines for deep venous thromboembolic disease prophylaxis in elective hip and knee replacement surgery. Are we nearer or further away from a consensus?]. / Las nuevas guías de profilaxis de enfermedad tromboembólica venosa en artroplastia de cadera y rodilla electivas: ¿nos acercamos o nos alejamos del consenso?

Venous thromboembolism events (VTE) prophylaxis after elective hip or knee replacement surgery is a subject of controversy. Three sets of guidelines (NICE, ACCP and AAOS) on this topic have recently been updated. The guidelines have points in common: prophylaxis is necessary, it is recommended to combine mechanical and pharmacological prophylaxis in patients who have suffered a previous VTE, isolated mechanical measures and low molecular weight heparins are effective, the new oral anticoagulants and fondaparinux are effective drugs. There is some consensus in recommending regional anaesthesia, in advising against echography studies in asymptomatic patients, and in the promotion of early mobilisation of the patient. There is controversy over the most suitable pharmacological treatment and the time of starting, and the duration of this, as well as on vena cava filters, antiplatelet drugs, and VTE or bleeding risk factors.

Hemiartroplastia cementada tras fractura subcapital de fémur. Análisis de supervivencia / Cemented hemiarthroplasty after a femoral neck fracture. Survivorship analysis

Objetivo. Analizar los factores que afectan a la supervivencia de sujetos tratados con hemiartroplastia tras una fractura subcapital de fémur.Material y método. Estudio retrospectivo de 1.196 fracturas subcapitales consecutivas en 1.166 pacientes tratados con hemiartroplastia de Thompson tras una fractura subcapital de fémur entre 1989 y 2001. Se realizó seguimiento clínico de una muestra aleatoria de 220 fracturas; de éstas, 210 casos fueron seguidos al menos dos años o hasta el fallecimiento (95,5%). Se realizó un análisis multivariante del efecto de laedad, el sexo, las enfermedades asociadas, la demora de la intervención quirúrgica y las complicaciones postoperatorias en la supervivencia. Se analizó también la supervivencia de los implantes.Resultados. La mediana de supervivencia fue de 4,5 años. El sexo masculino incrementaba la mortalidad (riesgo relativo [RR]= 2,47; intervalo de confianza para un 95% [IC 95%]: 1,65-3,70; p < 0,001) y también la edad avanzada (RR = 1,04; IC 95%: 1,01-1,07; p = 0,005). La demora de la intervención quirúrgica no afectaba la supervivencia a largo plazo, pero sí a los 6 meses teniendo los operados en el día del ingreso unamortalidad superior a la de los operados en los primeros 10 días tras el ingreso (33,3% frente a 10,4%; odds ratio [OR] = 4,38; IC 95%:1,12-16,5; p = 0,03). Sólo tres implantes fueron retirados, todos ellos por aflojamiento aséptico.Conclusiones. Los factores que más aumentan la mortalidaden este grupo de pacientes son el sexo masculino, laedad y la presencia de enfermedades. Una demora de la intervención de 24 horas puede aumentar la supervivencia a corto plazo. Los implantes rara vez fracasan

Purpose. To analyze the factors that affect the survivorship of subjects treated by hemiarthroplasty after a femoral neck fracture.Materials and methods. This is a retrospective study of1196 consecutive subcapital fractures in 1166 patients treated with a Thompson hemiarthroplasty between 1989 and2001 for a femoral neck fracture. A clinical follow-up was made of a random sample of 220 fractures. Of these, 210 cases were followed up for at least two years or until the patients’ death (95.5%). A multivariate analysis was carried out of the effect on survivorship of age, gender, associated conditions, delay of surgery and post-op complications. Implant survivorship was also analyzed.Results. Median survivorship was 4.5 years. Male genderhad a higher mortality rate (RR = 2.47, 95% confidence interval: 1.65-3.70; p < 0.001) as did old age (RR = 1.04, CI: 1.01-1.07; p = 0.005). Although, delay of surgery did not affect long-term survivorship, it did affect survivorship at 6 months: patients operated the same day they were admitted had a higher mortality rate than those operated in the first 10 days after admission (33.3% vs. 10.4%; OR = 4.38; CI: 1.12-16.5; p = 0.03). Only three implants had to be explanted,all of them further to aseptic loosening.Conclusions. The factors that most significantly contribute to mortality in this group of patients are male gender, age and the presence of a disease. A 24-hour delay of surgery can increase short-term survivorship. Implants rarely fail (AU)