Incidence of intraneural needle insertion in ultrasound-guided femoral nerve block: A comparison between the out-of-plane versus the in-plane approaches

BackgroundThe optimal method of ultrasound-guided femoral nerve block (in-plane vs. out-of-plane) has not been established. We tested the hypothesis that the incidence of needle-nerve contact may be higher with out-of-plane than with in-plane needle insertion.MethodsForty-four patients with hip fracture (American Society of Anaesthesiologists physical status I–III) were randomized to receive the femoral block with an out-of-plane approach (needle inserted at a 45–60° angle 1 cm caudal to the midpoint of the ultrasound probe just above the femoral nerve) or with an in-plane technique (needle inserted 0.2–0.4 cm from the side of the probe lateral to the femoral nerve). Data collected included depth of needle insertion, response to nerve electric stimulation, and distribution of the injected volume in relation to the nerve (anterior vs. posterior, the latter assuming needle-nerve contact). The sensory block onset was tested at 20 min and block recovery and any neurologic symptoms were evaluated at 24 h.ResultsThe incidence of needle-nerve contact was significantly higher with the out-of-plane approach (14/22 patients [64%]) than with the in-plane approach (2/22 patients [9%]) (p < 0.001) (OR = 17.5, 95% CI: 4–79). The rate of paraesthesia on crossing the fascia iliaca was similar in the two groups. All blocks uneventfully regressed; and no patient developed neurologic symptoms.ConclusionsUnder the conditions of our study, needle-nerve contact during femoral nerve block occurs frequently with the out-of-plane approach. An in-plane approach results in an equally effective femoral block and less incidence of needle-nerve contact.     

Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: a randomized controlled clinical trial

Study objectiveTo compare preoperative femoral (FNB) with combined femoral and sciatic nerve block (CFSNB) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction.DesignProspective, randomized clinical trial.SettingAmbulatory surgery center affiliated with an academic medical center.PatientsSixty-eight American Society of Anesthesiology physical status I and II patients undergoing arthroscopic ACL reconstruction.InterventionsSubjects randomized to the CFSNB group received combined femoral and sciatic nerve blocks preoperatively, whereas patients randomized to the FNB group only received femoral nerve block preoperatively. Both groups then received a standardized general anesthetic with a propofol induction followed by sevoflurane or desflurane maintenance. Intraoperative pain was treated with fentanyl. Pain in the postanesthesia care unit (PACU) was treated with ketorolac and opiates. Patients with significant pain despite ketorolac and opiates could receive a rescue nerve block.MeasurementsOur primary outcome variable was highest Numeric Rating Scale (NRS) pain score in PACU. NRS pain scores, opioid consumption, opioid adverse effects, and patient satisfaction were assessed perioperatively until postoperative day 3.Main resultsThe highest PACU NRS pain score was significantly higher in the FNB group compared with the CFSNB group (7 [3-10] vs 5 [0-10], P = .002). The FNB group required significantly larger doses of opioids perioperatively (31.8 vs 19.8 mg intravenous morphine equivalents, P < .001). PACU length of stay was significantly longer in the FNB group (128.2 vs 103.1 minutes, P = .006). There was no significant difference in opioid consumption, pain scores, or patient satisfaction on postoperative days 1-3 between groups.ConclusionsPreoperative CFSNB for arthroscopic ACL reconstruction improves analgesia, decreases opioid consumption perioperatively, and decreases PACU length of stay when compared with FNB alone.     

A comparison of treatment setting for elderly patients with hip fracture,is the geriatric ward superior to conventional orthopedic hospitalization?

IntroductionHip fractures in the elderly are a major cause of morbidity and mortality. The treatment settings of these patients may change their outcomes. The aim of this study is to compare the outcomes of patients with displaced femoral neck fractures who were admitted to the orthopedic vs. geriatric wards.Patients and methodsA retrospective study was conducted on 217 consecutive older patients with 219 displaced femoral neck fractures admitted either to the orthopedic or the geriatric ward between Jan. 2013 and Jun. 2015. Information regarding demographic, medical history, surgical management, hospitalization, and one year readmissions and mortality data was retrieved from electronic charts.Results102 hemiarthroplasty patients were admitted to the orthopedic ward and 117 to the geriatric ward. Patients' characteristics, including age, living arrangements, mobility status and the Charlson Comorbidity Index were similar between groups. Patients from the orthopedic ward had shorter hospitalization time (9 ± 5.1 vs. 10.8 ± 6.7 days, p = 0.022) and presented a lower in-hospital complication rates (0.6 ± 0.96 vs. 1 ± 1.9, p = 0.022), namely fewer events of urinary retentions, urinary tract infections and pneumonias (8.8% vs. 23.9%, p = 0.004, 3.9% vs. 14.5%, p = 0.010 and 2.9% vs. 12.2%, p = 0.034, respectfully). Readmission rates were similar. Neither in hospital nor one year mortality rates differed between groups.ConclusionsOur study found that geriatric care was not superior to orthopedic directed management in the treatment of elderly patients with hip fractures in terms of in-hospital complications, and hospitalization times.     

Potential pathogenic mechanism for stress fractures of the bowed femoral shaft in the elderly: Mechanical analysis by the CT-based finite element method

IntroductionStress fractures of the bowed femoral shaft (SBFs) may be one of the causes of atypical femoral fractures (AFFs). The CT-based finite element method (CT/FEM) can be used to structurally evaluate bone morphology and bone density based on patient DICOM data, thereby quantitatively and macroscopically assessing bone strength. Here, we clarify the pathogenic mechanism of SBFs and demonstrate this new understanding of AFFs through mechanical analysis by CT/FEM.Patients and methodsA prospective clinical study was performed from April 2012 to February 2014. We assembled two study groups, the bowed AFF group (n = 4 patients; mean age, 78.0 years) including those with a prior history of AFF associated with bowing deformity and the thigh pain group (n = 14 patients; mean age, 78.6 years) comprising outpatients with complaints of thigh pain and tenderness. Stress concentration in the femoral shaft was analysed by CT/FEM, and the visual findings and extracted data were assessed to determine the maximum principal stress (MPS) and tensile stress–strength ratio (TSSR). In addition, we assessed femoral bowing, bone density, and bone metabolic markers. Wilcoxon's rank sum test was used for statistical analysis.ResultsAll patients in the bowed AFF group showed a marked concentration of diffuse stress on the anterolateral surface. Thirteen patients in the thigh pain group had no significant findings. However, the remaining 1 patient had a finding similar to that observed in the bowed AFF group, with radiographic evidence of bowing deformity and a focally thickened lateral cortex. Patients were reclassified as having SBF (n = 5) or non-SBF (n = 13). Statistical analysis revealed significant differences in MPS (p = 0.0031), TSSR (p = 0.0022), and femoral bowing (lateral, p = 0.0015; anterior, p = 0.0022) between the SBF and non-SBF groups, with no significant differences in bone density or bone metabolic markers.ConclusionsSignificant tensile stress due to bowing deformity can induce AFFs. SBFs should be considered a novel subtype of AFF, and patients with complaints of thigh pain and femoral shaft bowing deformity must be considered at high risk for AFFs.This project (Ref: AOTAP 13-13) was supported by AOTrauma Asia Pacific.     

Femoral neck shortening in adult patients under the age of 55 years is associated with worse functional outcomes: Analysis of the prospective multi-center study of hip fracture outcomes in China (SHOC)

IntroductionYoung femoral neck fracture patients require surgical fixation to preserve the native hip joint and accommodate increased functional demands. Recent reports have identified a high incidence of fracture shortening and this may have negative functional consequences. We sought to determine if fracture shortening is associated with poor functional outcome in young femoral neck fracture patients.Patients and methodsOne hundred and forty-two patients with femoral neck fractures age 18–55 were recruited in this prospective cohort study across three Level 1 trauma hospitals in Mainland China. Patient-reported and objective functional outcomes were measured with the Harris Hip Score (HHS), Timed Up and Go (TUG), and SF-36 Physical Component Summary (SF-36 PCS) at 12 months. Radiographic fracture shortening was measured along the long axis of the femoral neck and corrected for magnification. Severe shortening was defined as ≥10 mm. The primary analysis measured associations between severe radiographic shortening and HHS at one-year post-fixation.ResultsOne hundred and two patients had complete radiographic and functional outcomes available for analysis at one year. The mean age of participants was 43.7 ± 10.8 years and 53% were male. Fifty-five percent of fractures were displaced and 37% were vertically orientated (Pauwels Type 3). The mean functional outcome scores were: HHS 90.0 ± 10.8, TUG 12.0 ± 5.1 s, and PCS 48.5 ± 8.6. Severe shortening occurred in 13% of patients and was associated with worse functional outcome scores: HHS mean difference 9.9 (p = 0.025), TUG mean difference 3.2 s (p = 0.082), and PCS mean difference 5.4 (p = 0.055).ConclusionsSevere shortening is associated with clinically important decreases in functional outcome as measured by HHS following fixation of young femoral neck fractures, occurring in 13% of patients in this population. The principle of fracture site compression utilized by modern constructs may promote healing; however, excessive shortening is associated with worse patient-reported outcomes and objective functional measures.     

Postoperative continuous-flow cryocompression therapy in the acute recovery phase of hip fracture surgery—A randomized controlled clinical trial

BackgroundThe acute recovery phase after hip fracture surgery is often complicated by severe pain, postoperative blood loss with subsequent transfusion, and delirium. Prevalent comorbidity in hip fracture patients limit the use of opioid-based analgesic therapies, yielding a high risk for inferior pain treatment. Postoperative cryotherapy is suggested to provide an analgesic effect, and to reduce postoperative blood loss. In this prospective, open-label, parallel, multicentre, randomized controlled, clinical trial, we aimed to determine the efficacy of continuous-flow cryocompression therapy (CFCT) in the acute recovery phase after hip fracture surgery.MethodsPatients with an intra or extracapsular hip fracture scheduled for surgery were included. Subjects were allocated to receive postoperative CFCT or usual care. The primary endpoint was numeric rating scale (NRS) pain the first 72 postoperative hours. Secondly, analgesic use; postoperative haemoglobin change and transfusion incidence; functional outcome; length of stay; delirium incidence; location of rehabilitation; patient-reported health outcome; complications and feasibility were assessed.ResultsSixty-one subjects in the control group, and 64 subjects in the CFCT group were analysed. Within the CFCT group, post treatment NRS pain declined 0.31 (p = 0.07) at 24 h, 0.28 (p = 0.07) at 48 h, and 0.47 (p = 0.002) at 72 h relative to pre treatment NRS pain. Sensitivity analysis at 72 h showed that NRS pain was 0.92 lower in the CFCT group when compared to the control group (1.50 vs. 2.42; p = 0.03). Postoperative analgesic use was comparable between groups. Between postoperative day one and three haemoglobin declined 0.29 mmol/l in the CFCT group and 0.51 mmol/l in controls (p = 0.06), and transfusion incidence was comparable. The timed up and go test and length of stay were also comparable between both groups. Complications, amongst delirium and cryotherapy-related adverse events were not statistically significantly different. Discharge locations did not differ between groups. At outpatient follow-up subjects did not differ in patient-reported health outcome scores. Subjects rated CFCT satisfaction with an average of 7.1 out of 10 points.ConclusionsNo evidence was recorded to suggest that CFCT has an added value in the acute recovery phase after hip fracture surgery. If patients complete the CFCT treatment schedule, a mild analgesic effect is observed at 72 h.     

Good functional outcome but not regained health related quality of life in the majority of 20–69 years old patients with femoral neck fracture treated with internal fixation: A prospective 2-year follow-up study of 182 patients

Background and purposeProspective studies on patient related outcome in patients <70 years with a femoral neck fracture (FNF) are few. We aimed to investigate functional outcome and health-related quality of life (HRQoL) in 20–69 years old patients with a FNF treated with internal fixation.Patients and methods182 patients, 20–69 years with a FNF treated with internal fixation were prospectively included in a multicenter study. Follow up included radiographic and clinical examination at 4, 12 and 24 months. Collected data were hip function using Harris Hip Score (HHS), HRQoL (EQ-5D and SF-36), fracture healing and re-operations.ResultsAt 24 months, HHS was good or excellent in 73% of the patients with a displaced fracture and 85% of the patients with a non-displaced fracture (p = 0.15). Of the patients with displaced fracture (n = 120), 23% had a non-union (NU) and 15% had an avascular necrosis (AVN) with a 28% re-operation rate. None of the patients with non-displaced fracture (n = 50) had an NU, 12% had a radiographic AVN and 8% needed a re-operation. The mean EQ-5D_index in patients with displaced fracture decreased from 0.81 to 0.59 at 4 months, 0.63 at 12 months and 0.65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 0.88, 0.69, 0.75 and 0.74 respectively (p < 0.001). The mean SF-total score in patients with displaced fracture decreased from 76 to 55 at 4 months, 63 at 12 months and 65 at 24 months (p < 0.001). The corresponding values for patients with non-displaced fracture were 80, 67, 74 and 76 respectively (p < 0.001).InterpretationTwo thirds of the patients with displaced femoral neck fracture healed after one operation and three quarters reported good or excellent functional outcome at 24 months. However, they did not regain their pre-fracture level of HRQoL.     

Alterações no nível de TNF‐α após bloqueio do nervo femoral guiado por ultrassom em idosos com fratura de quadril

Background and objectives

An ultrasound guided femoral nerve block is an established analgesic method in patients with a hip fracture. Elevated cytokine levels correlate with poor patient outcomes after surgery. Hence, the aim of the study was to describe the levels of tumor necrosis factor‐α after an ultrasound‐guided femoral nerve block in elderly patients having a femoral neck fracture.

Trochanteric entry femoral nails yield better femoral version and lower revision rates—A large cohort multivariate regression analysis

IntroductionIntramedullary nailing (IMN) has become the standard of care for the treatment of most femoral shaft fractures. Different IMN options include trochanteric and piriformis entry as well as retrograde nails, which may result in varying degrees of femoral rotation. The objective of this study was to analyze postoperative femoral version between three types of nails and to delineate any significant differences in femoral version (DFV) and revision rates.Materials & methodsOver a 10-year period, 417 patients underwent IMN of a diaphyseal femur fracture (AO/OTA 32A-C). Of these patients, 316 met inclusion criteria and obtained postoperative computed tomography (CT) scanograms to calculate femoral version and were thus included in the study. In this study, our main outcome measure was the difference in femoral version (DFV) between the uninjured limb and the injured limb. The effect of the following variables on DFV and revision rates were determined via univariate, multivariate, and ordinal regression analyses: gender, age, BMI, ethnicity, mechanism of injury, operative side, open fracture, and table type/position. Statistical significance was set at p < 0.05.ResultsA total of 316 patients were included. Piriformis entry nails made up the majority (n = 141), followed by retrograde (n = 108), then trochanteric entry nails (n = 67). Univariate regression analysis revealed that a lower BMI was significantly associated with a lower DFV (p = 0.006). Controlling for possible covariables, multivariate analysis yielded a significantly lower DFV for trochanteric entry nails than piriformis or retrograde nails (7.9 ± 6.10 vs. 9.5 ± 7.4 vs. 9.4 ± 7.8°, p < 0.05). Using revision as an endpoint, trochanteric entry nails also had a significantly lower revision rate, even when controlling for all other variables (p < 0.05).ConclusionComparative, objective comparisons between DFV between different nails based on entry point revealed that trochanteric nails had a significantly lower DFV and a lower revision rate, even after regression analysis. However, this is not to state that the other nail types exhibited abnormal DFV. Translation to the clinical impact of a few degrees of DFV is also unknown. Future studies to more in-depth study the intricacies of femoral version may lead to improved technology in addition to potentially improved clinical outcomes.     

Does femoral offset recover and affect the functional outcome of patients with displaced femoral neck fracture following hemiarthroplasty?

BackgroundRestoring preoperative horizontal femoral offset (FO) promised good functional outcome in patients receiving total hip arthroplasty. However, relatively little was known regarding the clinical relevance of restoring the offset in patients with bipolar hemiarthroplasty to treat displaced femoral neck fracture. Therefore, the objective of this study was to evaluate postoperative FO accurately and verify its relation with functional outcome.MethodsOne hundred elderly patients who received bipolar hemiarthroplasty to treat displaced femoral neck fracture were identified. Preoperative CT scanning of contralateral hip joint and reconstruction of images led to rotation-free FO. By referencing postoperative implant specification and comparing to measured values in Picture Archive and Communication System, rotation-free postoperative FO and the amount of change were acquired. Postoperative Harris Hip Score (HHS) and Modified Barthel Index (MBI) were evaluated to measure functional outcome at 12-month after the surgery. Patients with significant FO change were identified. Multiple regression analysis was conducted to determine if the FO change might independently affect the outcome regardless of confounding factors.ResultsThe mean preoperative offset was 37.4 ± 2.5 increased by 12.7 ± 9.6% after the surgery. Only 25.0% of postoperative offset after hemiarthroplasty was changed within ±5% of preoperative offset. A total of 45.0% of postoperative offset changed within ±10% while 77.0% of postoperative offset changed within ±20%. 23% of patients whose FO changed more than 20% showed significantly worse outcome score than the patients whose FO change remained within ±20% of initial value. Mean MBI and HHS were negatively correlated with FO change. After adjusting for confounding factors, significant correlation remained between modification of FO and MBI, but not between FO change and HHS (B = 4.576; β = 0.235; 95% confidence interval of B: 0.534 to 8.135).ConclusionsFO was not properly restored in 23% of subjects receiving bipolar hemiarthroplasty due to femoral neck fracture. FO restoration independently predicted fair MBI after the surgery. Therefore, surgeons should pay attention to restoring FO with meticulous templating.     

Fixation of displaced femoral neck fractures in young adults: Fixed-angle devices or Pauwel screws?

BackgroundWe sought to compare the incidence of complications after fixation of displaced femoral neck fractures in young adults treated with fixed-angle devices versus multiple cancellous screws and a trochanteric lag screw (Pauwel screw).MethodsWe conducted a retrospective cohort study at a level I trauma centre. Sixty-two skeletally mature patients (age range, 16–60 years) with displaced femoral neck fractures were included in the study. Forty-seven were treated with a fixed-angle device (sliding hip plate with screw or helical blade) and 15 with multiple cancellous screws placed in a Pauwel configuration. The main outcome measure was postoperative complication of osteonecrosis or nonunion treated with a surgical procedure.ResultsSignificantly fewer failures occurred in the fixed-angle group (21%) than in the screws group (60%) (p = 0.008). Osteonecrosis was rare in the fixed-angle group, occurring in 2% of cases versus 33% of cases in the screws group (p = 0.002). Consistent with previous studies, good to excellent reductions were associated with a failure rate of 25% and fair to poor reductions were associated with a failure rate of 55% (p = 0.07). The best-case scenario of a good to excellent reduction stabilised with a fixed-angle device yielded a success rate of 85%.ConclusionIn young patients with displaced high-energy femoral neck fractures, fixed-angle devices resulted in fewer treatment failures than did Pauwel screws.     

Location of atypical femoral fracture can be determined by tensile stress distribution influenced by femoral bowing and neck-shaft angle: a CT-based nonlinear finite element analysis model for the assessment of femoral shaft loading stress

IntroductionLoading stress due to individual variations in femoral morphology is thought to be strongly associated with the pathogenesis of atypical femoral fracture (AFF). In Japan, studies on AFF regarding pathogenesis in the mid-shaft are well-documented and a key factor in the injury is thought to be femoral shaft bowing deformity. Thus, we developed a CT-based finite element analysis (CT/FEA) model to assess distribution of loading stress in the femoral shaft.Patients and MethodsA multicenter prospective study was performed at 12 hospitals in Japan from August 2015 to February 2017. We assembled three study groups—the mid-shaft AFF group (n = 12), the subtrochanteric AFF group (n = 10), and the control group (n = 11)—and analyzed femoral morphology and loading stress in the femoral shaft by nonlinear CT/FEA.ResultsFemoral bowing in the mid-shaft AFF group was significantly greater (lateral bowing, p < 0.0001; anterior bowing, p < 0.01). Femoral neck-shaft angle in the subtrochanteric AFF group was significantly smaller (p < 0.001). On CT/FEA, both the mid-shaft and subtrochanteric AFF group showed maximum tensile stress located adjacent to the fracture site. Quantitatively, there was a correlation between femoral bowing and the ratio of tensile stress, which was calculated between the mid-shaft and subtrochanteric region (lateral bowing, r = 0.6373, p < 0.0001; anterior bowing, r = −0.5825, p < 0.001).ConclusionsCT/FEA demonstrated that tensile stress by loading stress can cause AFF. The location of AFF injury could be determined by individual stress distribution influenced by femoral bowing and neck-shaft angle.     

Does restoration of leg length and femoral offset play a role in functional outcome one year after hip hemiarthroplasty?

BackgroundThe objective of this study was to evaluate the correlation between specific joint biomechanical parameters and 1 year functional outcome scores in elderly patients receiving hemiarthroplasty in the setting of intracapsular hip fractures.MethodsThis is a retrospective, institutional registry based study. 168 hip hemarthroplasties were captured from October 2013 to June 2015. Patients were excluded based on contralateral hip surgery, perioperative complications or inadequate radiographs. 84 patients were alive at one year follow up. We compared mobility and pain scores to radiographically determined variations of leg lengths and femoral offset. We also compared the performance of fellowship trained arthroplasty surgeons to their non-fellowship trained counterparts.ResultsThe operated leg was a mean of 1.12 ± 6.8 mm longer than the contralateral. leg length discrepancy (LLD) was less than 10 mm in 72 patients. Mean difference in offset between limbs was 0.25 ± 3.3 mm. The difference was within 5 mm in 79 patients (94%). We found no statistically significant correlation between mobility or pain scores and variations in leg length or offset. We found significantly better performance of the arthroplasty surgeons in restoring leg length but no difference in offset reconstruction or functional benefit for the patient.ConclusionsOur study was unable to demonstrate a significant relationship between leg length or femoral offset restoration and the patient’s ultimate functional recovery. Arthroplasty surgeons performed better in restoring leg length, but no associated functional advantage was seen.     

Effectiveness of controlled telescoping system for lateral hip pain caused by sliding of blade following intramedullary nailing of trochanteric fracture

IntroductionThe purpose of this study was to demonstrate the effectiveness of controlled telescoping system for lateral hip pain caused by sliding of the blade following intramedullary nailing of trochanteric fractures.Materials and methodsA retrospective cohort study was performed to compare the controlled telescoping system (Compression Hip Nail; CHN) with the conventional sliding system (Proximal Femoral Nail Antirotation; PFNA) for trochanteric fractures. 74 cases in the PFNA group and 77 cases in the CHN group were included from two university hospitals in this study. All patients had a minimum of 12-month follow up period. Lateral hip pain was evaluated and operation time and blood loss during the surgery were measured. The fracture classification was evaluated. The quality of postoperative reduction and other complications after surgery were also evaluated and tip-apex distance (TAD), telescoping and lateral protrusion of the blade and lag screw were measured.ResultsThe mean age was 78.5 years in the PFNA group and 74.7 years in the CHN group (p = 0.25). The mean telescoping was 19.2 mm in the PFNA group and 10.7 mm in the CHN group (p < 0.001). The mean length of lateral protrusion was 10.5 mm in the PFNA group and 2.5 mm in the CHN group (p < 0.001). Twenty-eight patients in the PFNA group complained of lateral hip pain, whereas 12 patients in the CHN group did (p = 0.002). These four variables showed statistically significant differences between the PFNA and CHN groups (p < 0.05). The length of lateral protrusion was the only variable significantly related to lateral hip pain through multivariate logistic regression analysis (p = 0.045).ConclusionsThe degree of lateral protrusion was mainly related to lateral hip pain. Therefore, controlled telescoping would help to decrease lateral hip pain by decreasing the lateral protrusion beyond the lateral femoral cortex.     

Eficácia do bloqueio do plano do músculo eretor da espinha guiado por ultrassom para analgesia após colecistectomia laparoscópica: um estudo controlado randômico

Background and objectivesThe primary aim of this study is to assess the effect of ultrasoung‐guided erector spinae block on postoperative opioid consumption after laparoscopic cholecystectomy. The secondary aims are to assess the effects of erector spinae plane block on intraoperative fentanyl need and postoperative pain scores.MethodsPatients between 18‐70 years old, ASA I‐II were included in the study and randomly allocated into two groups. In Group ESP, patients received bilateral US‐ESP with 40 ml of 0.25% bupivacaine at the level of T7, while in Group Control, they received bilateral US‐ESP with 40 ml of saline before the induction of anesthesia. Then a standard general anesthesia procedure was conducted in both groups. NRS scores at the postoperative 15th, 30th, 60th minutes, 12th and 24th hours, intraoperative fentanyl need and total postoperative tramadol consumption were recorded.ResultsThere were 21 patients in Group ESP and 20 patients in Group Control. Mean postoperative tramadol consumption was 100 ± 19.2 mg in Group ESP, while it was 143 ± 18.6 mg in Group Control (p < 0.001). The mean intraoperative fentanyl need was significantly lower in Group ESP (p = 0.022). NRS scores at the postoperative 15th, 30th min, 12th hour and 24th hour were significantly lower in ESP group (p < 0.05). According to repeated measures analysis, NRS score variation over time was significantly varied between two groups (F[1,39] = 24.061, p < 0.0005).ConclusionsBilateral US‐ESP block provided significant reduction in postoperative opioid consumption, intraoperative fentanyl need and postoperative pain scores of patients undergoing laparoscopic cholecystectomy.     

The treatment strategies of intertrochanteric fractures nonunion: An experience of 23 nonunion patients

BackgroundIntertrochanteric femoral fractures are common, but the nonunion of intertrochanteric fractures is not. The purpose of this study was to divide intertrochanteric fracture nonunion into different types and give corresponding treatment strategies.MethodsWe retrospectively evaluated 23 patients with intertrochanteric fracture nonunion. The patients were divided into five groups and each group was treated with a different strategy. All patients had staged clinical and radiographic follow-ups and the mean follow-up was 16.0 ± 4.6 months.ResultsExcept for the patients treated with total hip arthroplasty, all patients achieved fracture union. The mean union time was 4.7 ± 1.2 months. The Harris hip function score differed significantly from preoperative (28.9 ± 6.8) to postoperative (83.8 ± 6.3; p < 0.05). For the three patients who were classified as type III, the femoral neck shaft angle was corrected to a significant degree, from 97.3 ± 6.4 to 127.3 ± 2.5 (p < 0.05). For the four patients who were classified as type V, the mean time from debridement to re-internal fixation was 3.7 ± 1.5 months.ConclusionsThere are several factors associated with the failure of intertrochanteric fracture treatments. We need to analyze the causes of fracture treatment failure carefully. Based on our five classifications and corresponding treatment strategies, the radiographic and functional treatment outcomes were satisfactory. Future larger comparative studies are needed to confirm our results.     

The contribution of periapical nerve block in transrectal ultrasound-guided prostate biopsy: Results from a prospective randomized trial

ObjectivePeriprostatic nerve block has been shown to be the most effective method to reduce pain during transrectal ultrasound (TRUS) guided prostate biopsy, but the ideal technique remains controversial. The aim of this study was to compare pain control between bilateral basal block (BBB) alone and BBB combined with periapical nerve block (PNB).Patients and methodsFrom November 2007 to May 2009, 182 consecutive patients with abnormally elevated serum prostate-specific antigen (PSA) or suspicious digital rectal examination (DRE) underwent TRUS-guided needle biopsy of the prostate. The patients were prospectively randomized after informed consent had been obtained. Group 1 (n = 90) underwent bilateral basal block (BBB) with periprostatic infiltration of 8 ml 1% lidocaine into the neurovascular bundle at the prostate-seminal vesicle junction on each side. Group 2 (n = 92) underwent BBB with the addition of periapical nerve block (PNB) using 2 ml 1% lidocaine per side. A visual analog scale (VAS) was used to evaluate the patient's perception of pain during the biopsy.ResultsThe mean patient age was 64.6 ± 8.2 years and the average VAS was 1.9 ± 2.0. The mean VAS was lower in Group 2 compared with Group 1, 1.6 ± 1.9 versus 2.2 ± 2.0 (p = 0.026). In the subgroup aged 56–65 years the mean VAS was 1.26 ± 0.6 in Group 1 versus 2.46 ± 0.5 in Group 2 (p = 0.001), and in the subgroup aged 66–87 years it was 1.41 ± 0.5 in Group 1 versus 1.66 ± 0.75 in Group 2 (p = 0.554).ConclusionsBBB combined with PNB seems to be more effective to BBB alone to reduce pain during TRUS-guided prostate biopsy and may be of maximum benefit for younger patients.     

High prevalence of simultaneous rib and vertebral fractures in patients with hip fracture

PurposeThe purpose was to evaluate the prevalence and location of simultaneous fracture using bone scans in patients with hip fracture and to determine the risk factors associated with simultaneous fracture.Patients and methodsOne hundred eighty two patients with hip fracture were reviewed for this study. Clinical parameters and bone mineral density (BMD) of the lumbar vertebra and femoral neck were investigated. To identify acute simultaneous fracture, a bone scan was performed at 15.4 ± 4.1 days after hip fracture. The prevalence and location of simultaneous fracture were evaluated, and multivariate logistic regression analysis was performed to determine the risk factors.ResultsSimultaneous fracture was observed in 102 of 182 patients, a prevalence of 56.0%. Rib fracture was the most common type of simultaneous fracture followed by rib with vertebral fracture. The BMD of the lumbar vertebra was significantly lower in patients with simultaneous fracture (p = 0.044) and was identified as an independent risk factor (odds ratio: OR 0.05, 95% confidence interval: CI 0.01–0.57).ConclusionsThe prevalence of simultaneous fracture was relatively high among patients with hip fracture, and BMD was significantly lower in patients with simultaneous fracture than in patients without it. Surgeons should be aware of the possibility of simultaneous fracture in patients with hip fracture.     

Single shot spinal anaesthesia with hypobaric bupivacaine for hip fracture repair surgery in the elderly. Randomized,double blinded comparison of 3.75 mg vs. 7.5 mg

BackgroundArterial hypotension is the most frequent adverse effect of subarachnoid anaesthesia in the elderly sustaining a femoral proximal fracture. Decreasing the local anaesthetic dose reduces the incidence of hypotension but shortens sensory block duration that could be insufficient in some surgical procedures. Sensory block duration could be prolonged using hypobaric local anaesthetics. We evaluated whether low hypobaric bupivacaine doses were adequate for this type of surgery while maintaining the haemodynamic stability.MethodsA prospective, randomized, double blinded study was designed. Patients over 65 years old, sustaining traumatic hip fracture, were assigned to one of two groups: B0.5 group, hypobaric bupivacaine 7.5 mg 5 mg/ml (control group), and B0.25 group, hypobaric bupivacaine 3.75 mg 2.5 mg/ml (study group). After subarachnoid injection, sensory level and motor blockade degree were registered, as were blood pressure, and heart rate at basal time and at 2, 5, 10, 15, 20 and 30 min after injection. The doses of vasopressor needed were registered as well. Surgical conditions and the duration of the surgical procedure—whether rescue analgesia or anaesthesia was needed—and sensory level regression to T12, were registered as well.ResultsSixty four patients was the calculated sample size. The study was stopped in an interim analysis because an elevated number of patients in the B0.25 group needed iv rescue anaesthesia. In the analyzed cases, blood pressure was significantly lower in the B0.5 group at the 15 and 30 min measurements. Vasopressor drugs needs were similar between groups [ephedrine accumulated mean (SD) doses 11.4 (5.2) mg vs. 9.1 (2.7) mg, p = 0.045)]. Sensory block regression to T12 was faster in the B0.25 group, [(mean (SD) 68.2 (29.0) min vs. 112.8 (17.3) min in the B0.5 group, p < 0.05]. Five out of 19 patients in the B0.25 group needed intravenous anaesthesia rescue before surgery started.ConclusionLowering hypobaric bupivacaine dose to 3.75 mg in subarachnoid anaesthesia for hip fracture repair surgery in elderly patients decrease intraoperative blood pressure, but in an important number of patients intravenous anaesthesia rescue was needed and preclude recommendation.     

Single shot spinal anesthesia with very low hyperbaric bupivacaine dose (3.75 mg) for hip fracture repair surgery in the elderly. A randomized,double blinded study

PurposeSingle shot spinal anesthesia is used worldwide for hip fracture repair surgery in the elderly. Arterial hypotension is a frequent adverse effect. We hypothesized that lowering local anesthetics dose could decrease the incidence of arterial hypotension, while maintaining quality of surgical anesthesia.MethodsIn a randomized double blinded study, 66 patients over the age of 65 years, with hip fracture needing surgical repair, were assigned to B0.5 group 7.5 mg hyperbaric bupivacaine 5 mg/ml (control group), and B0.25 group 3.75 mg hyperbaric bupivacaine 2.5 mg/ml (study group). Sensory and motor block level, and hemodynamic parameters including blood presure, heart rate and vasopressor dose administration were registered, along with rescue anesthesia needs, the feasibility of surgery, its duration, and regression time of sensory anesthesia to T12.ResultsAfter exclusions, 61 patients were included in the final analysis. Arterial hypotension incidence was lower in the B0.25 group (at the 5, 10, and 15 min determinations), and a lower amount of vasopressor drugs was needed (mean accumulated ephedrine dose 1.6 mg vs. 8.7 mg in the B0.5 group, p < 0.002). Sensory block regression time to T12 was shorter in the B0.25 group, mean 78.6 ± 23.6 (95% CI 51.7–110.2) min vs. 125.5 ± 37.9 (95% CI 101.7–169.4) min in the B0.5 group, p = 0.033. All but one patient in the B0.25 group were operated on under the anesthetic procedure first intended. No rescue anesthesia was needed.ConclusionLowering bupivacaine dose for single shot spinal anesthesia for hip fracture repair surgery in elderly patients was effective in decreasing the occurrence of arterial hypotension and vasopressor use, while intraoperative quality remained.