Background

Acute pain following total knee replacements (TKRs) is associated with higher peri-operative opiate requirements and their side effects, longer hospital stay and lower patient satisfaction (Petersen 2014). It may also be associated with higher rates of chronic pain at 1 and 5 years (Beswick 2012). We present a novel technique using combination of Local Infiltration Anaesthesia (LIA) with PainKwell infusion system (Bupivacaine 0.5 @ 4mls and 6mls/hr) to improve pain management following TKRs.

Background

Hip arthroplasties are associated with high postoperative pain scores. In some reports, moderate to severe pain was 58% on the first day postoperatively in total hip replacements (THRs). Several techniques are currently used at our institution to tackle acute pain following THRs. These include: 1) Spinal anaesthetic (SA) with Diamorphine only; 2) General anaesthetic (GA) only; 3) SA with local infiltration anaesthetic mixture 1 (LIA1,). Mixture 1 consisted of ropivacaine, adrenaline, and ketorolac; 4) SA with LIA mixture 2 (LIA2). Mixture 2 consisted of bupivacaine and adrenaline; 5) SA with LIA1 and PainKwell pump system. In this study we report on the techniques of acute pain control following THR at our regional centre for elective primary THRs.

Background

Pain control following knee replacement (TKR) surgery is often poor. Moderate to severe pain is often reported in the first 48 hours following surgery requiring opiate analgesia. The Local Infiltration Anaesthetic (LIA) technique has been described as a method to reduce post operative pain. In this study we report on our experience using LIA in addition to the PainKwell system (Peak Medical) of continuous infusion intra-articularly, of 0.25% bupivacaine at 4–5 mls/hour for 48 hours post surgery. The PainKwell catheter is placed in the knee joint during surgery.

Aim:This study was carried out to assess various factors responsible for the development of avascular necrosis and the effect of treatment on clinical outcome.

Methods: We studied the clinical notes and radiographs of patients presenting with SCFE during the period between 1994 and 2003.

Results: Seventy three patients (n=73) with ninety two (n=92) hips were included in the study. There were 16 acute, 43 acute-on-chronic, 29 chronic and 4 preslips. Seventy Seven (n = 77) slips were classified as stable and 15 as unstable slips. Fifty three slips (57.6%) were mild, 34 (37%) were moderate and five (5.4%) were severe slips. Despite no deliberate attempts to reduce the slip at the time of surgery eighteen hips (n=18) showed a median decrease in slip angle of 8 degrees (range 2–36) in acute and acute-on-chronic slips. The mean preoperative slip angle was 32 degrees (range 9–76) compared to postoperative slip angle of 29.9 degrees (range 10–75) (p=0.004). Four patients developed avascular necrosis (AVN). Intraoperative reduction of the slip was significantly related to development of AVN (p< 0.001). According to the criteria of Heyman and Herndon eight patients had functional deficit at the time of final follow up and clinical outcome was fair, poor or failure. All of these patients had a reduction in the angle of slip at the postoperative radiographs compared to their preoperative radiographs.

Conclusion: Reduction of slipped capital femoral epiphysis is responsible for poor outcome and also related to the development of avascular necrosis. We recommend single in situ pinning for these cases regardless of severity of slip.

Background: Subacromial decompression surgery is associated with significant postoperative pain. We compared the effect of intrascalene block (ISB) and sub-acromial bursa block (SBB) with simple opiate based analgesia

Methods: In a prospective, randomised controlled trial, fifty-three (n = 53) patients scheduled for arthroscopic subacromial decompression were randomised into three groups receiving Intrascalene block (n =19), Subacromial Bursa block (n =19) or neither of the two blocks (n =15 controls). Patients with cuff pathology were excluded. ISB was performed preoperatively with 20 mls of 1% Prilocaine and 10 mls of 0.5 % Bupivacaine. SBB was given with 20 mls of 0.5% Bupivacaine postoperatively. All patients received standardised general anaesthetic and postoperative analgesia. Pain, sickness and sedation scores were noted at 1, 2, 4, 8, 12 and 24 hours postoperatively. The postoperative consumption of morphine and the time when the first bolus of morphine was required were also noted.

Results: The visual analogue pain scores in the ISB and SBB group were lower than the control group in the first twelve hours postoperatively achieving statistical significance but there were no significant differences between the SBB and ISB groups. The controls consumed more morphine postoperatively (mean 32.3 mls) than SBB (21.21 mls) and ISB groups (14.00 mls) (p < 0.001). The time for first bolus was earlier in the controls (mean 30.2 mins) as compared to both SBB (72.7 mins) and ISB groups (105.8 mins) (p< 0.001). The oral analgesic intake was less in the SBB and ISB groups than the controls (p = 0.004), but there was no difference between the two treatment groups.

Conclusion: Whilst intrascalene block remains the gold standard where expertise is available for its administration, subacromial bursa block is a safe alternative in patients with intact rotator cuff undergoing arthroscopic subacromial decompression.

We report a retrospective review of the incidence of venous thromboembolism in 463 consecutive patients who underwent primary total hip arthroplasty (487 procedures). Treatment included both total hip replacement and hip resurfacing, and the patients were managed without anticoagulants. The thromboprophylaxis regimen included an antiplatelet agent, generally aspirin, hypotensive epidural anaesthesia, elastic compression stockings and early mobilisation. In 258 of these procedures (244 patients) performed in 2005 (cohort A) mechanical compression devices were not used, whereas in 229 (219 patients) performed during 2006 (cohort B) bilateral intermittent pneumatic calf compression was used.

All operations were performed through a posterior mini-incision approach. Patients who required anticoagulation for pre-existing medical problems and those undergoing revision arthroplasty were excluded. Doppler ultrasonographic screening for deep-vein thrombosis was performed in all patients between the fourth and sixth post-operative days. All patients were reviewed at a follow-up clinic six to ten weeks after the operation. In addition, reponse to a questionnaire was obtained at the end of 12 weeks post-operatively.

No symptomatic calf or above-knee deep-vein thrombosis or pulmonary embolism occurred. In 25 patients in cohort A (10.2%) and in ten patients in cohort B (4.6%) asymptomatic calf deep-vein thromboses were detected ultrasonographically. This difference was statistically significant (p = 0.03). The regimen followed by cohort B offers the prospect of a low incidence of venous thromboembolism without subjecting patients to the higher risk of bleeding associated with anticoagulant use.