New modalities of pain treatment after outpatient orthopaedic surgery.

Postoperative pain relief is one of the cornerstones of success of orthopaedic surgery. Development of new minimally-invasive surgical procedures, as well as improvements in pharmacological and local and regional techniques should result in optimal postoperative pain control for all patients. The analgesic strategy has to be efficient, with minimal side effects, and be easy to manage at home. Multimodal analgesia allows for a reduction of opiate use and thereby its side effects. Local and regional analgesia is a major component of this multimodal strategy, associated with optimal pain relief, even upon mobilization, and it has beneficial effects on postoperative recovery. Ultrasound guidance improves the success rate of distal nerve blocks and makes distal selective blockade possible, helping to preserve the limb's motility. Besides peripheral nerve blocks, local infiltration (incisional and/or intra-articular) is also important to consider. Duration of the nerve blockade is limited after a single injection. This must be taken into consideration to avoid the recurrence of pain when the patient returns home. Continuous perineural blocks using catheters are an option that can be easily managed at home with monitoring by home-care nurses. Extended-release liposomal bupivacaine and adjuvants such as dexamethasone could significantly enhance the duration of the sensory block, thereby reducing the indications for pain pumps. Non-pharmacological approaches, such as cryotherapy, hypnosis and acupuncture should not be ignored.

Perioperative management of proximal hip fractures in the elderly: the surgeon and the anesthesiologist.

The comprehensive management of proximal hip fractures in elderly patients requires dedicated and responsive teamwork. Elderly patients often present with several comorbidities and the immediate treatment of a fracture has to optimize both medical therapy and analgesic control in order to reduce surgical and anesthetic complications and to preserve as much cognitive functioning as possible. The elderly are uniquely exposed to complications related to bed rest, delirium and postoperative cognitive dysfunction (POCD), which appear to be independent factors of morbidity. Anesthetic management that includes good perioperative pain management can influence the patient's inflammatory response and possibly decrease the incidence of POCD. The best choice of surgical treatment depends on the type of fracture as well as the patient's age and medical condition. However, the type of anesthesia management, which includes neuraxial blocks, peripheral nerve blocks and/or general anesthesia, has to be tailored towards generated the best outcome. We present a review from a surgical and anesthetic perspective on the most common perioperative issues in proximal fracture repair.

Reduction of operating and recovery room times and overnight hospital stays with interscalene blocks as sole anesthetic technique for rotator cuff surgery.

BACKGROUND: The effort to decrease hospital stays and to increase operating room efficacy has become an important consideration in the practice of anesthesia. METHODS: Fifty-three patients who underwent shoulder rotator cuff repair in the sitting position were divided into four groups according to the anesthesia technique used: Group 1 (general anesthesia), Group 2 (interscalene block), Group 3 (interscalene combined with general anesthesia) and Group 4 (general anesthesia combined with local injection of local anesthetics). Interscalene blocks were performed preoperatively, using a nerve stimulator. After appropriately locating the brachial plexus, a mixture of 40 ml of 2% lidocaine and 0.5% bupivacaine (v/v) was injected. RESULTS: As compared to general anesthesia, the use of an interscalene block alone reduced the following operating room times: 1) from the patient's arrival in the operating room to the beginning of surgery and 2) from the end of surgery to the patient's departure from the operating room. Use of the interscalene block also resulted in a reduction of recovery time when compared to Groups 1, 3 and 4 by 40, 56 and 66%, respectively. Compared to Group 1, this anesthesia technique was furthermore associated with a 64% decrease in the number of patients hospitalized overnight. CONCLUSIONS: This study confirms that the interscalene block as sole anesthesia technique is safe and effective and can contribute to shorten the hospital length of stay of patients undergoing shoulder rotator cuff surgery.