Wound Infiltration with Levobupivacaine, Ketorolac, and Adrenaline for Postoperative Pain Control after Spinal Fusion Surgery.

STUDY DESIGN: This study enrolled patients in from a single center who underwent primary spinal fusion procedure and divided them into two groups (group-control study). PURPOSE: Good local infiltration can reduce postoperative analgesic requirements and enable expedited discharge. Administration of a combination of levobupivacaine (200 mg/100 mL, 0.9% normal saline), ketorolac (30 mg), and adrenaline (0.5 mg) as a wound infiltrate is recommended at an optimum combination. OVERVIEW OF LITERATURE: There is currently no consensus on the optimum intraoperative local infiltration of spinal surgery patients undergoing operative fusion. METHODS: Patients who were enrolled in two spinal centers (over 24 months) undergoing primary spinal fusion procedures were allocated into two groups, comparing the type of local infiltration used at the time of the procedure. Group 1 received the combination of levobupivacaine (200 mg), ketorolac (30 mg), and adrenaline (0.5 mg), while group 2 received other types of local anesthetics. Primary outcome measures include patient-controlled analgesia (PCA) use, morphine consumption, and length of hospital stay. Secondary outcome measure are as follows: days of physiotherapy, pain score, side effects, and complications. RESULTS: There are a total of 140 patients enrolled. Seventy-five patients enrolled were allocated to group 1, receiving the study combination, and 65 patients were assigned in group 2, receiving other local infiltrations. All primary outcome measures (consumption of morphine, use of PCA, and length of stay) were significantly higher in group 2 than the study combination (p<0.05). The secondary outcomes of pain scores and days of physiotherapy values were also significantly higher in group 2 (p<0.05). Patient satisfaction questionnaires gave significantly better results in group 1 (p<0.05). There were no significant statistical differences with regard to any postoperative complications between the two groups. CONCLUSIONS: Our data suggest that the studied wound infiltration is a safe and feasible option that could provide good postoperative pain control without significant side effects. It also allowed to reduce dependence of opioids and PCA, earlier postoperative mobilization, lower pain scores postoperatively, and reduced hospital stay.

Intramuscular Injection Abscess Due to VRSA: A New Health Care Challenge.

Abscess formation following intramuscular injections is rare and they are most commonly seen in immunocompromised individuals. In this case series we present a cohort of three patients presented to us in a critically ill condition with an abscess due to intramuscular injection. Vancomycin resistant staphylococcus aureus was isolated from all three patients. These patients posed a major challenge to the healthcare system and the treating physician because of the: severity of illness, virulence and resistance of the organism, rarity of the situation, immune state of the patient, and lack of supporting evidence to properly guide management in the use of health resources. To the best of our knowledge, there is no report available in the English literature on vancomycin resistant staphylococcus aureus associated with intramuscular injection abscess.

Rotator cuff tears: An evidence based approach.

Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations - cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being cost-effective, this helps in providing a functional shoulder with a stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, cost-effective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.

"WhatsApp"ening in orthopedic care: a concise report from a 300-bedded tertiary care teaching center.

Smartphones have emerged as essential tools providing assistance in patient care, monitoring, rehabilitation, communication, diagnosis, teaching, research and reference. Among innumerable communication apps, WhatsApp has been widely popular and cost effective. The aim of our study was to report the impact of introduction of a smartphone app "WhatsApp" as an intradepartmental communication tool on (1) awareness of patient-related information, (2) efficiency of the handover process and (3) duration of traditional morning handovers among orthopedic residents in a 300-bedded tertiary care teaching center. Written handovers and paging used for communication at our center led to occasional inefficiencies among residents. Widespread use, low cost, availability and double password protection (phone lock and WhatsApp lock) made WhatsApp's group conversation feature an ideal tool for intradepartmental patient-related communication. Twenty-five consecutive admissions before and after WhatsApp (BW, AW) were included in the study. Eight orthopedic residents attempted fifty randomly arranged questions based on the twenty-five patients in each study period. A null hypothesis that introduction of WhatsApp group would neither increase the awareness of patient-related information nor improve the efficiency of the handovers among residents was assumed. A significant improvement observed in scores obtained by residents in the AW group led to rejection of the null hypothesis. The residents also reported swifter and efficient handovers after the introduction of WhatsApp. Our results indicate that the introduction of a smartphone app "WhatsApp" as an intradepartmental communication tool can bring about an improvement in patient-related awareness, communication and handovers among orthopedic residents.

Vertical dislocation of the patella: report of 2 cases.

Vertical dislocation of the patella is rare and usually occurs as a result of blunt trauma. The patella rotates around a vertical axis. It can be diagnosed by its typical clinical features. This article presents a case of 2 patients with vertical dislocation who presented with high-impact injuries and had classic signs of a vertically dislocated patella. Unlike lateral patella dislocation, reduction under sedation is usually not possible. This is mainly due to increased tension within the quadriceps mechanism, which makes reduction difficult. The other factor that makes reduction difficult is that the patella could be wedged in the femoral condyles. Both patients underwent multiple unsuccessful attempts at reduction in the emergency department. These were later successfully reduced under general anesthesia and both patients went on to make an uneventful recovery. Multiple attempts without adequate relaxation could not only cause chondral damage but could also could endanger the extensor mechanism.

Critical analysis of outcome measures used in the assessment of carpal tunnel syndrome.

Clinicians and researchers are confounded by the various outcome measures used for the assessment of carpal tunnel syndrome (CTS). In this study, we critically analysed the conceptual framework, validity, reliability, responsiveness and appropriateness of some of the commonly used CTS outcome measures. Initially, we conducted an extensive literature search to identify all of the outcome measures used in the assessment of CTS patients, which revealed six different carpal tunnel outcome measures [Boston Carpal Tunnel Questionnaire (BCTQ), Michigan Hand Outcome Questionnaire (MHQ), Disability of Arm, Shoulder and Hand (DASH), Patient Evaluation Measure (PEM), clinical rating scale (Historical-Objective (Hi-Ob) scale) and Upper Extremity Functional Scale (UEFS)]. We analysed the construction framework, development process, validation process, reliability, internal consistency (IC), responsiveness and limitations of each of these outcome measures. Our analysis reveals that BCTQ, MHQ and PEM have comprehensive frameworks, good validity, reliability and responsiveness both in the hands of the developers, as well as independent researchers. The UEFS and Hi-Ob scale need validation and reliability testing by independent researchers. Region-specific measures like DASH have good frameworks and, hence, a potential role in the assessment of CTS but they require more validation in exclusive carpal tunnel patients.

Immediate unprotected weight-bearing of operatively treated ankle fractures.

The objective of this study was to determine whether immediate mobilisation and unprotected weight-bearing of rigidly internally fixed fractured ankles had a significant effect on ankle function or whether it predisposed the ankle to loss of reduction or hardware failure. Twenty five patients with operated Weber A/B/C fractures were allowed immediate full weight-bearing without a plaster and were compared with matched historical controls treated in a non-weight-bearing plaster cast. Matched-pair analysis revealed no differences for hospital stay and functional outcome on Olerud and Molander scoring system but significant difference in time until return to work (mean: 91.3 +/- 20.2 vs. 54.6 +/- 15.5 days). In the cast group four patients had postoperative complications; one patient had loss of internal fixation and one had non-union while four patients in the non cast group had mainly wound-healing related problems. Patients in the non cast group tolerated earlier full weight-bearing compared with patients in the cast group, and there were no disadvantages concerning hospital stay, pain intensities, and functional scores. Treating patients without plaster may result in faster rehabilitation.

Analysis of methodological deficiencies of studies reporting surgical outcome following cemented total-joint arthroplasty of trapezio-metacarpal joint of the thumb.

Cemented total-joint arthroplasty has been increasingly used in the treatment of end stage arthritis of the thumb trapeziometacarpal joint. Evidence supporting its use in the treatment of trapeziometacarpal disorders in the literature is very limited. Most hand surgeons agree that there are concerns about the methodological quality of the limited literature available. In this study, we analysed the methodological quality of the outcome studies on cemented total-joint arthroplasty of the thumb. We included all the outcome studies published in the English literature on cemented total-joint arthroplasty of the trapeziometacarpal joint of thumb. We analysed these studies for methodological deficiencies and quality of outcome reporting based on the recommendations given by Coleman et al. Our study revealed that there were no uniform standards of outcome reporting. The mean Coleman score for the studies dealing with cemented total-joint arthroplasty of the thumb was 42.9. Major deficiencies were identified in areas like subject selection criteria (0/15), type of study (5.7/15), description of surgical procedure (3.7/5), description of the rehabilitation protocol (2/10), outcome measures (4.4/10) and outcome assessment (3.9/15). The methodological quality of the studies published within the last 10 years (49.9+/-9.7) was found to be slightly better than the studies published over 10 years ago (39.7+/-7.8). Our study highlights the need for more evidence in the form of randomised controlled prospective studies conducted with good methodological quality, comparing the cemented total-joint arthroplasty of the thumb to other procedures available for the treatment of disorders of the thumb. Further, to improve the standards of reporting, journal editors should try to standardise the outcome of the reporting by following the surgical procedures on the thumb.

Thromboprophylaxis following cast immobilisation for lower limb injuries--survey of current practice in United Kingdom.

The risk of deep vein thrombosis (DVT) and pulmonary embolism (PE) is well documented in patients following cast immobilisation for injuries of lower extremities. There are no generally accepted approaches to preventing this complication and hence there remains substantial practice variation amongst surgeons regarding the use of anticoagulation measures. The present survey was conducted to investigate the current chemothromboprophylaxis practice among UK orthopaedic departments for patients immobilised with plasters for lower extremity injuries and establish any variations in practice. A telephone questionnaire survey was conducted on junior doctors (Senior House Officers and Registrars) in orthopaedic departments of 70 randomly selected hospitals in United Kingdom. This survey assessed the thromboprophylaxis practice for lower limb injuries in plaster casts. Our results show substantial variation amongst British orthopaedic surgeons in the use of chemothromboprophylaxis measures. Sixty-two percent of the departments do not use any DVT prophylaxis in this group of trauma. Furthermore, only 11.4% of the departments performed risk stratification on their patients. Ninety-nine percent of the respondents were unaware of any existing guidelines in this regard. Although the incidence of DVT in patients in plaster for lower extremity injuries is low compared to the Hip/Knee arthroplasty group, this is not insignificant. Both over and under treatment with thromboprophylaxis can have implications in terms of side effects and costs. One possible solution is to use risk stratification to identify individuals who are likely to benefit from prophylaxis. There is a substantial variation and inconsistency in practice among orthopaedic departments in United Kingdom due to a lack of clinical guidelines in this group of trauma and it remains underused even in high-risk group.

Reliability of radiological classifications used in Legg-Calve-Perthes disease.

Radiological assessment is a valuable tool in the assessment, management and prognostication of Perthes disease. Radiological assessment, however, is not an easy task and all classification systems used in Perthes disease have some degree of interrater and intrarater variabilities. In the past, there were some isolated studies to find the reliability of the classifications used in Perthes disease. In this study, we comprehensively studied three most commonly used radiological classifications (Salter-Thompson, lateral pillar and Catterall). We had 44 patients' radiographs (anteroposterior and lateral) taken in the fragmentation stage, and two experienced observers assessed and classified the radiographs on two separate occasions. In this study, we found that the average interrater reliability of the Salter-Thompson, lateral pillar and Catterall classifications was 0.163 (0.08-0.236), 0.722 (0.581-0.824) and 0.433 (0.280-0.546), respectively. The intrarater reliability was 0.313 and 0.699 for the Salter-Thompson, 0.707 and 0.658 for the lateral pillar and 0.38 and 0.577 for the Catterall classifications. Further, we tried to determine the possible reason for the low reliability associated with the Catterall classification. We think that the quantitative method of lateral pillar has better intrarater and interrater reliabilities than other classification systems, and the reliability of the Catterall classification can be significantly improved if some radiological parameters such as metaphyseal reaction and identification of the junction of involved to uninvolved region can be optimized.

Stress radiography in the assessment of residual deformity in clubfoot following postero-medial soft tissue release.

X-ray is important in the assessment of clubfoot. Stress radiographs give more information than routine radiographs. Because of the inaccuracy of the positioning and the disadvantages of radiation, paediatric orthopaedic surgeons do not like and do not use X-ray examination. In this study we report a technique we use to obtain stress radiographs in paediatric patients with clubfoot using a custom-made radiolucent modular splint. This technique provides better assessment of the initial status and the result of treatment. Although this method has limitations it can help to compare different feet and treatment results with regard to axis and angle. We validated this splint by means of a prospective study in 11 patients with 21 feet having type 2 clubfoot who underwent (PMSTR) in our centre. Two sets of radiographs were taken, one with manual positioning and one with our splint. We found significant differences in the values of midfoot and forefoot radiological parameters between the two sets. We found that the correlation between the clinical and radiological assessment of residual deformity improved significantly for these values when a splint was used to obtain stress views. Hence we recommend routine use of a radiolucent splint for taking stress views to assess residual deformity in clubfoot.

A missed injury in multiple trauma patient-is it avoidable?

We report a case of a 24-year-old male with fractures at multiple levels of both femur and tibia. The patient was operated upon and a satisfactory clinical outcome was achieved. In spite of a thorough secondary survey, a displaced ankle fracture had been missed. The case is reported for the unusual combination of fractures and to highlight the importance of undetected injuries. We recommend that a tertiary survey should be carried out routinely in all polytrauma patients to prevent missed injuries.

An unusual cause of acute carpal tunnel syndrome.

Acute carpal tunnel syndrome following anticoagulation is uncommon. We describe a case in which the diagnosis was missed on three previous presentations by several clinicians. Although the presentation is typical, lack of awareness of this complication, inability to notice subtle signs and failure to do INR may lead to missing the diagnosis.

Gonadal shields in pelvic radiographs in pediatric patients.

We performed a retrospective study of pelvic radiographs of children between August 2003 and January 2004 to determine whether gonadal shields effectively protected the gonads during pelvic radiographs in pediatric patients. We considered 1,047 radiographs of 111 children under the age of 16 years who were examined by the orthopaedic department at the University Hospital of North Staffordshire. The presence and absence of gonadal shields in all the pelvic radiographs was recorded. If the shields were present, then whether the gonads were effectively protected was recorded. An average of 9.4 radiographs were taken per patient. The gonadal shields effectively protected the gonads in 466 (49.2%) radiographs and were completely omitted in 270 (28.5%) radiographs. In the remaining 212 (22.3%) radiographs, the shields did not adequately protect the gonads, which were therefore exposed to radiation in 482 (50.8%) of all the eligible pelvic radiographs. Children receive many radiographs with avoidable excess radiation from inadequate positioning or complete omission of gonadal shields. This may increase the potential for disease in the future offspring of these patients. Strict adherence to guidelines is required to decrease radiation exposure.