Intrathecal morphine in combination with bupivacaine as pre-emptive analgesia in posterior lumbar fusion surgery: a retrospective cohort study.

BACKGROUND: The purpose of this study was to evaluate the efficacy of intrathecal morphine (ITM) in combination with bupivacaine as pre-emptive analgesia in patients undergoing posterior lumbar fusion surgery. This is in comparison with traditional opioid analgesics such as intravenous (IV) morphine. METHODS: Two groups were identified retrospectively. The first (ITM group) included patients who had general anaesthesia (GA) with low-dose spinal anaesthesia prior to induction using 1-4 mls of 0.25% bupivacaine and 0.2 mg ITM. 1 ml of 0.25% bupivacaine was administered per hour of predicted surgery time, up to a maximum of 4 ml. The insertion level for the spinal anaesthetic corresponded to the spinal level of the iliac crest line and the level at which the spinal cord terminated. The control group had GA without any spinal anaesthesia. Patients were instead administered opioid analgesia in the form of IV morphine or diamorphine. The primary outcome was the consumption of opioids administered intraoperatively and in recovery, and over the first 48 h following discharge from the post-anaesthesia care unit (PACU). Total opioid dose was measured, and a morphine equivalent dose was calculated. Secondary outcomes included visual analogue scale (VAS) pain scores in recovery and at day two postoperatively, and the length of stay in hospital. RESULTS: For the ITM group, the median total amount of IV morphine equivalent administered intraoperatively and in recovery, was 0 mg versus 17 mg. The median total amount morphine equivalent, administered over the first 48 h following discharge from PACU was 20 mg versus 80 mg. Both are in comparison with the control group. The median length of stay was over 1 day less and the median VAS for pain in recovery was 6 points lower. No evidence was found for a difference in the worst VAS for pain at day two postoperatively. CONCLUSION: ITM in combination with bupivacaine results in a significantly decreased use of perioperative opioids. In addition, length of hospital stay is reduced and so too is patient perceived pain intensity. Trial registration The study was approved by the ethics committee at The Robert Jones and Agnes Hunt Orthopaedic Hospital as a service improvement project (Approval no. 1617_004).

Entrapment of the sciatic nerve following closed reduction of a dislocated revision total hip replacement.

Injury to the sciatic nerve following closed manipulation of a dislocated total hip replacement is rare. We present such a case in an elderly patient with partial recovery following exploration and release of the nerve.

Ilizarov principles of deformity correction.

Ilizarov frames provide a versatile fixation system for the management of bony deformities, fractures and their complications. The frames give stability, soft tissue preservation, adjustability and functionality allowing bone to realise its full osteogenic potential. It is important that we have a clear and concise understanding of the Ilizarov principles of deformity correction to best make use of this fixation system. In this review article, the history of Ilizarov frame, the basic sciences behind it, the mechanical principles governing its use and the clinical use of the fixation system are discussed.

Idiopathic severe elevation of serum alkaline phosphatase following adult renal transplantation: case reports.

Transient hyperphosphatasemia (TH) in infancy is a benign condition characterized by elevated alkaline phosphatase (ALP) levels severalfold the adult upper limits, occurring mainly in children under 5 years, without evidence of liver or bone disease, and a return to normal ALP levels by 4 months. Herein we have reported 3 cases of TH in adults following renal transplantation. The first case, a 47-year-old woman, blood group AB positive, had hypertensive renal disease. Five months after successful renal transplantation from a deceased donor she had a 50-fold increase in ALP. The second case, a 34-year-old man, blood group A positive, had renal failure due to IgA nephropathy. Nine weeks after a second renal transplant from a deceased donor a 25-fold increase in ALP was noted. The third case, a 45-year-old woman, blood group A positive, experienced renal failure 15 years earlier of unknown etiology. Thirteen years after her second renal transplant a 12-fold increase in ALP was observed during a routine follow-up. In all cases, the isolated ALP serum levels returned to normal limits within 12 weeks. Bone scans and abdominal ultrasounds during these periods were normal with no evidence of bone or liver disease. ALP isoenzyme electrophoresis revealed a pattern characteristic of TH of infancy and childhood. The 3 cases reported highlight the occurrence of benign TH in adults, with renal transplantation. However, liver disease, bone disease, and infection should be excluded first in these susceptible individuals on immunosuppression before establishing the diagnosis of TH.

Management of clinical radial nerve palsy with closed fracture shaft of humerus--a postal questionnaire survey.

The management of radial nerve palsy associated with fracture shaft of humerus is still a matter of debate. Various studies based on surgical and conservative management of this clinical problem have shown good results. After a recent systematic review by Shao et al. we felt that it was timely to survey the current practice among trauma and orthopaedic surgeons in England. Postal questionnaires were sent to orthopaedic surgeons in the north of England. The response rate was 64%. The survey showed that surgeons still differ in the ways of management of radial nerve palsy associated with fracture shaft of humerus, with a slightly higher percentage of surgeons preferring conservative treatment. The study also reveals the current practice of immobilisation, investigations and the duration of expectant treatment before surgical exploration among surgeons in the north of England.

Lateral Radiograph of the Hip in Fracture Neck of Femur: Is it a Ritual?

INTRODUCTION: Historically routine work up of a patient with a fracture neck of femur has always included an antero-posterior (AP) and a lateral view of the hip. The aim of the study was to know whether a lateral view of hip influenced the decision of an Orthopedic Surgeon regarding management at a District General Hospital. METHODS: A prospective study was conducted from February 2005 to September 2005 at Tameside General Hospital. X-rays of patients admitted with fracture neck of femur were shown to two independent observers in the daily trauma meeting. AP view of the hip was shown initially to observers and their classification and intended treatment was recorded. They were asked if they needed a lateral view to decide on management option and answers were recorded. The observers were then showed a lateral view of same hip and asked to comment on quality of film and also whether it would change their classification or intended management. RESULTS: There were 100 patients over six months. On AP view 56 were classified to have extra-capsular fracture, 37 were classified as displaced subcapital fracture and seven were classified undisplaced subcapital fracture. There was an interobserver variation in one patient between undisplaced or displaced subcapital fracture. The observers felt they would need a lateral X-ray on three occasions and there was a change in classification from undisplaced subcapital to displaced subcapital fracture on first occasion. There was no change in management plan in all the 100 patients after looking at a lateral X-ray. CONCLUSION: We can conclude that unless required for management a lateral X-ray of hip should be avoided routinely in all patients with fracture neck of femur as it would not only be cost effective but will also reduce radiation exposure to patient and relieve work pressure on radiographers, nursing and portering staff.