Control of postoperative pain in knee arthroplasty: single dose femoral nerve block versus continuous femoral block

IntroductionTo compare the efficacy of a multimodal analgesia with 2 different techniques (femoral nerve block with a single dose and continuous femoral nerve block) in the control of pain, use of opioids, and secondary effects in patients subjected to total knee replacement.Material and methodsA prospective randomised study of patients subjected to knee replacement with subarachnoid anaesthesia. The postoperative analgesia consisted of tramadol, dexketoprofen and paracetamol, and one of the following techniques: Femoral nerve block with a single dose of 30 mL of 0.5% ropivacaine, or that dose plus a continuous infusion via a femoral catheter of 0.375% ropivacaine 6 ml/h for 48 h. The demographic, anaesthetic and surgical variables were recorded, along with the pain intensity using a visual analogue scale, opioid use, and complications at 24 and 48 h after surgery.ResultsA total of 104 patients were included. There no differences in the demographic data between the groups. The pain intensity was lower in the group that had continuous femoral block, particularly at 48 h, compared to the single-dose block, and with a lower use of rescue analgesia in the continuous femoral block. The incidence in secondary effects was similar, with a lower long-term sensory block being observed in the femoral block with a single dose.ConclusionsThe use of peripheral nerve block is accepted practice for analgesia after knee replacement surgery. Continuous femoral block is a valid alternative, decreasing the use of rescue opiates and pain intensity (particularly at 48 h) compared to isolated femoral block.     

Risk factors for symptomatic venous thromboembolism following surgery for closed ankle fractures: A case-control study

BackgroundWe analyzed risk factors for venous thromboembolism (VTE) within 6 months after surgery for closed ankle fractures.MethodsThis was a case-control study based on data from chart review in a cohort of patients having open reduction and internal fixation (ORIF) for closed ankle fractures in two large general hospitals 2009–2011. Cases with symptomatic VTE (pulmonary embolism or deep venous thrombosis) were identified in the cohort, and additional cases of VTE were identified by computerized search of discharge diagnoses in the same hospitals in 2004–2008 and 2012–2016. In total, we identified 60 cases with VTE and compared with 240 randomly selected controls among 998 patients without VTE in the cohort. Risk factors were assessed using logistic regression analysis.ResultsAmong cases, 27 (45%) had pulmonary embolism, 33 (55%) deep venous thrombosis. Those with VTE were older, had higher BMI, had more often a family history of VTE, and more often had antibiotic prophylaxis during surgery than controls. In multivariable logistic regression analysis age/10 (OR 25.75, 95%CI 3.52–188.44, p = 0.001), (age/10)² (OR 0.77, 95%CI 0.65–0.93, p = 0.005), BMI (1.15 per kg/m², 95%CI 1.07–1.24, p < 0.001) and Charlson comorbidity index ≥2 vs.0 (OR 0.27, 95%CI 0.08–0.92, p = 0.036) and 1 vs. 0 (OR 0.27, 95%CI 0.09–0.86, p = 0.026) were associated with VTE within 6 months of surgery.ConclusionsThe odds of symptomatic VTE within 6 months of ORIF increased with increasing age and BMI, but were lower with increasing comorbidity.     

Factors associated with rapid progression to knee arthroplasty: complete analysis of three-year data from the osteoarthritis initiative

ObjectivesOnly a few studies have identified prognostic factors indicating risk of future knee arthroplasty in patients with osteoarthritis (OA) of the knee. The Osteoarthritis Initiative (OAI) is a National Institutes of Health and privately funded cohort study of 4796 persons with or at high risk of knee OA. The OAI is ideally suited to a more extensive study of knee arthroplasty prognostic factors than has been undertaken. The purpose of our study was to identify patient factors which predict rapid progression to knee arthroplasty, defined as arthroplasty within three years of baseline data collection.MethodsWe used alternating logistic regression models to analyze complete three year follow-up data from the OAI on 4670 persons with, or at risk for knee OA, aged 45 to 79 years during the years 2004 to 2008.ResultsA total of 128 knees (116 persons) underwent knee arthroplasty during the study period. After adjusting for known prognostic factors, several previously unidentified predictors of future knee arthroplasty were found including past history of knee surgery (RR = 2.04, 95% CI = 1.33, 3.13), knee flexion contracture in degrees (RR = 1.06, 95% CI = 1.02, 1.11) and pain, on a 0 to 10 scale, with active knee flexion (RR = 1.58, 95% CI = 1.04, 2.39).Discussion/ConclusionsThis study identifies new and easily measured clinical variables that are associated with more rapid progression to arthroplasty. The data may help to inform both physicians and patients of medical history and clinical examination findings most highly associated with short-term arthroplasty.     

Pilot study on the use of acoustic radiation force impulse imaging in the staging of cystic fibrosis associated liver disease

BackgroundAcoustic radiation force impulse (ARFI) is a novel technique for the measurement of hepatic stiffness, which could be valuable in clinical follow-up of patients affected by cystic fibrosis liver disease (CFLD).MethodsSeventy-five patients with suspected CFLD (35 males) underwent clinical and ultrasonographic evaluations, liver and pulmonary function tests, ARFI investigation, and upper gastrointestinal endoscopy. Ten ARFI measurements were taken at the deep right hepatic lobe to compute median values of Shear Wave Velocity (SWV) for each individual.ResultsSWV increased progressively from 1.02 m/s (95%, Confidence Interval, CI, 0.92–1.126) in patients with no evidence of CFLD at ultrasonography (N = 16), to 1.12 (95%CI 1.049–1.19) in patients with CFLD and no signs of portal hypertension (PHT, N = 23), and to 1.25 (95%CI 1.14–1.358) in those with CFLD and signs of PHT (N = 28). SWV was 1.63 (95%CI 1.26–1.99) in patients with oesophageal varices (N = 8) (p < 0.0001).ConclusionsARFI may represent an easy, fast and non-invasive tool for the clinical follow-up of patients with cystic fibrosis associated liver disease.     

Modification of percutaneous vertebroplasty for painful old osteoporotic vertebral compression fracture in the elderly: preliminary report

ObjectiveTo study the clinical efficacy of modified percutaneous vertebroplasty (PVP) in the treatment of painful old osteoporosis vertebral compression fractures (OVCF).MethodsFrom April 2007 to October 2009, 16 cases (23 vertebrae) of symptomic old OVCF were treated with a modified PVP. Before operation, all the patients were examined by standing anteroposterior and lateral X-Ray and MRI. The pain level of each patient was assessed before operation and 1 week, 6, 12 months after the operation using visual analogue scale (VAS) and Oswestry disability index (ODI). The middle line vertebral body height and local sagittal Cobb's angle were also measured.ResultsPostoperative average VAS, Oswestry disability index (ODI), the local sagittal Cobb's angle decreased from 7.8, 72.3%, and 38.2° to 3.1, 26.8%, and 21.5° respectively before and after surgery (p < 0.05). The mean midline vertebral height increased from 13.8 mm to 26.6 mm before and after surgery (p < 0.05). There was no infection, nerve injury, pulmonary embolism, or death after operation.ConclusionsThe modified PVP can increase the space for bone cement filling and is good for the restoration of vertebral body height. It is an optimal procedure for the treatment of painful old OVCF.     

The efficacy of balneotherapy and mud-pack therapy in patients with knee osteoarthritis

ObjectivesKnee osteoarthritis (OA) is a common chronic degenerative disorder. There are various treatment modalities. This study was planned to investigate the efficacy of balneotherapy, mud-pack therapy in patients with knee OA.MethodsA total of 80 patients with knee OA were included. Their ages ranged between 39–78. The patients were separated in to three groups. Group I (n = 25) received balneotherapy, group II (n = 29) received mud-pack therapy and group III (n = 26) was hot-pack therapy group. The therapies were applied for 20 min duration, once a day, five times per week and a total of 10 session. Patients were assessed according to pain, functional capacity and quality of life parameters. Pain was assessed by using Visuel Analogue Scale (VAS) and Western Ontario McMaster Osteoarthritis Index (WOMAC) pain scale (0–4 likert scale). Functional capacity was assessed by using WOMAC functional capacity and WOMAC global index. Quality of life was evaluated by Nottingham Health Profile (NHP) self-administered questionnaire. Also physician's global assessment and the maximum distance that patient can walk without pain, were evaluated. The assessment parameters were evaluated before and after three months.ResultsThere were statistically significant improvement in VAS and WOMAC pain scores in group I (p < 0.001), group II and III (p < 0.05). The WOMAC functional and global index also decreased in group I (p < 0.05), group II (p < 0.001) and hot-pack group (p < 0.05). Quality of life results were significantly improved in balneotherapy and mud-pack therapy groups (p < 0.05). No difference was observed in hot-pack therapy group (p > 0.05). The maximum distance was improved both in group I and II (p < 0.05) but not in group III. Also physician's global assessment was found to be improved in all groups (p < 0.05).ConclusionsBalneotherapy and mud-pack therapy were effective in treating patients with knee OA.     

Symptomatic acute coronary syndrome in a cohort of patients followed after noncardiac surgery

ObjetivesTo determine the incidence of acute coronary syndrome (ACS) with and without ST-segment elevation, factors related to the development of ACS, mean hospital stay, and attributable mortality.Material and methodsIn a noncardiac surgery cohort attended in the postoperative critical care unit of Hospital General de la Ciudad Real, Spain, data were recorded prospectively between April 2006 and December 2009. The incidence of symptomatic ACS was calculated.ResultsThirty-two of 1919 patients developed ACS (incidence, 1.7%). Patient factors related to developing the syndrome were male sex (P = .046), age (P = .001), arterial hypertension (68.8%, P = .012), and a history of ischemic heart disease (34.4%, P = .001). Types of surgery that were significantly related to developing ACS were general surgery (37.5%), orthopedic or trauma surgery (28.1%), and vascular surgery (15.6%) (P < .004). Twenty percent of the cohort received transfusions; 50% of those who developed ACS were transfused (P = .001). The condition was treated medically in 87.5% of the cases. The mean (SD) duration of hospital stay was 2.96 (6.3) days for the cohort and 3.88 (5) days for patients who developed ACS (P = .39); mortality rates were 5% and 6%, respectively (P = .45). Multivariate analysis confirmed that the following independent variables were associated with developing postoperative ACS: a history of ischemic heart disease (odds ratio [OR], 4.59; 95% confidence interval [CI], 1.98–10.62) and intraoperative bleeding (OR, 3.18; 95% CI, 1.51–6.71). Gynecologic surgery patients were the least likely to develop postoperative ACS (OR, 0.063; 95% CI, 0.004–1.09).ConclusionsThe incidence of postoperative ACS in this noncardiac surgery cohort was 1.7%. Age, male sex, a history of arterial hypertension or ischemic heart disease, type of surgery, and intraoperative bleeding requiring transfusion of packed red blood cells are factors that are associated with developing this complication. Given the seriousness of ACS it is important to classify patients by risk before surgery.     

Polymorphisms in the estrogen receptor genes are associated with hip fractures in Chinese

IntroductionHip fractures (HF) are a major cause of public health burden with strong genetic determination. However, the true causal genes remain largely unknown.Materials and methodsBased on the important biological role of estrogens in bone homeostasis, this study aimed to investigate whether the estrogen receptor genes, ESR1 and ESR2, affect the onset of HF in 700 elderly Chinese subjects (350 with osteoporotic HF and 350 healthy controls). We genotyped 32 SNPs in total and examined their associations both by the single-SNP and haplotype tests.ResultsWe identified two novel SNPs of ESR1, rs3020314 and rs1884051, were significantly associated with HF (rs3020314: P = 0.0004, OR = 1.66, 95%CI: 1.25–2.18; rs1884051: P = 0.0004, OR = 1.46, 95%CI: 1.19–1.81). We firstly detected significant association of ESR2 with HF (rs960070: P = 0.0070, OR = 1.43, 95%CI: 1.10–1.86). Haplotype analyses corroborated our single-SNP results.ConclusionOur findings have important implications for understanding the pathology of osteoporotic fractures. Independent replication studies are needed to validate our results and explore the most possible functional variants for molecular studies.     

Remifentanil as an alternative to epidural analgesia for vaginal delivery: A meta-analysis of randomized trials

ObjectivesAlthough epidural analgesia is considered the gold standard for labor pain management, its use may be restricted in some conditions due to clinical contraindications or availability, and suitable alternatives may be required. The objective of this meta-analysis was to determine whether evidence from randomized trials suggests remifentanil PCA (R-PCA) results in significant differences in maternal satisfaction, analgesic efficacy, and safety compared with conventional epidural analgesia (EA).DesignWe conducted a meta-analysis after systematically searching MEDLINE, EMBASE and Cochrane Library for all randomized controlled trials (RCTs) allocating parturients to R-PCA or EA and reporting at least one outcome of interest.PatientsEight randomized trials of R-PCA vs EA with 2351 patients were included.MeasurementsThe primary outcome of interest was maternal satisfaction. Secondary outcomes included visual analog pain score (VAS at 1, 2, 3 h postoperatively), nausea, vomiting, pruritus, hypoxemia, acute respiratory depression or death (maternal or neonatal), need for Cesarean section, and neonatal Apgar score.Main resultsMeta-analysis of the randomized trials showed no significant differences between the R-PCA and EA groups for maternal satisfaction, VAS at 2 or 3 h, nausea, vomiting, need for cesarean section, respiratory depression, umbilical pH, and neonatal Apgar score at 1 min and 5 min. However, incidence of hypoxemia was higher [OR 7.48, 95%CI 3.42–16.36] and VAS at 1 h was slightly higher [WMD 1.33, 95%CI 0.30–2.36] with R-PCA versus EA. Pruritus was less frequent in the R-PCA group [OR 0.54, 95%CI 0.32–0.89]. Acute respiratory failure and death were not reported in any of the studies.ConclusionsWhile no significant differences were detected for maternal satisfaction or for most clinical outcomes, this meta-analysis remains underpowered to rule out clinically-important differences due to the few existing randomized trials. For obstetric patients who are not candidates for EA, R-PCA may provide an alternative for analgesia in the peri-partum period, but caution is warranted particularly regarding hypoxemia, and suggests the need for increased surveillance and monitoring for R-PCA. Further adequately powered randomized trials with a focus on clinically-relevant maternal and neonatal outcomes are required to more accurately characterize the relative benefits and risks of R-PCA versus EA in this population.     

Resección transuretral en bloque vs. resección transuretral convencional para el cáncer de vejiga primario no músculo-infiltrante: metaanálisis

IntroductionWe performed a meta-analysis to evaluate the effect of en-bloc transurethral resection vs. conventional transurethral resection for primary non-muscle invasive bladder cancer.MethodsA systematic literature search up to January 2022 was done and 28 studies included 3714 primary non-muscle invasive bladder cancer subjects at the start of the study; 1870 of them were en-bloc transurethral resection, and 1844 were conventional transurethral resection for primary non-muscle invasive bladder cancer. We calculated the odds-ratio (OR) and mean-difference (MD) with 95% confidence-intervals (CIs) to evaluate the effect of en-bloc transurethral resection compared with conventional transurethral resection for primary non-muscle invasive bladder cancer by the dichotomous or continuous methods with random or fixed-effects models.ResultsEn-bloc transurethral resection had significantly lower twenty-four-month recurrence (OR: 0.63; 95%CI: 0.50-0.78; P < 0.001), catheterization-time (MD: –0.66; 95%CI: –1.02-[–0.29]; P < 0.001), length of hospital stay (MD: –0.95; 95%CI: –1.55-[–0.34]; P = 0.002), postoperative bladder irrigation duration (MD: –6.06; 95%CI: –9.45-[–2.67]; P < 0.001), obturator nerve reflex (OR: 0.08; 95%CI: 0.02-0.34; P = 0.03), and bladder perforation (OR: 0.14; 95%CI: 0.06-0.36: P < 0.001) and no significant difference in the 12-month-recurrence (OR: 0.79; 95%CI: 0.61-1.04; P = 0.09), the operation time (MD: 0.67; 95%CI: –1.92-3.25; P = 0.61), and urethral stricture (OR: 0.46; 95%CI: 0.14-1.47; P = 0.19) compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects.ConclusionsEn-bloc transurethral resection had a significantly lower twenty-four-month recurrence, catheterization time, length of hospital stay, postoperative bladder irrigation duration, obturator nerve reflex, bladder perforation, and no significant difference in the twelve-month recurrence, operation time, and urethral stricture compared with conventional transurethral resection for primary non-muscle invasive bladder cancer subjects. Further studies are required.     

Trauma surgery by general surgeons: Still an option for proximal femoral fractures?

IntroductionSurgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored.MethodsPatients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were >170/year (high volume), 96–170/year (medium volume) and <96/year (low volume).ResultsIn 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p = 0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580–0.958; p = 0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995–0.999; p = 0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997–1.018; p = 0.175).ConclusionSurgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures.     

The baseline glomerular filtration rate,predictive of six-year survival in sub-Saharan African patients on antiretroviral therapy for HIV: Cohort study

BackgroundRecently, serious morbidity events associated with initial glomerular filtration rate (GFR) have been described during HIV infection, but this is insufficiently investigated in sub-Saharan Africa very affected by HIV.ObjectiveTo assess the impact of baseline GFR prevailing during the first semester of the HIV infection management on six-year survival in peoples taking antiretroviral therapy.Patients and methodsClosed retrospective cohort study. The death was the expected outcome, the baseline GFR (mL/min/1.73 m²) in the first semester of the follow-up was the main exposure. Kaplan–Meier method, Cox regression were used for analysis.ResultsAccording to baseline GFR: < 60, 60–89 and ≥ 90, the six-year survival was 81.6%; 95.8% and 96.4% (P = 0.067 Breslow). Adjusted hazard ratio for baseline GFR < 60 and 60–89 (vs. ≥ 90) were respectively 5.4 (95%CI: 1.4–19.9; P = 0.012) and 1.2 (95%CI: 0.3–4.0; P = 0.754). The etiological fraction of deaths attributable to baseline GFR: GFR < 60: 81% (95%CI: 0.31–0.95), GFR = 60–89: 18.0% (95%CI: −0.7–0.8). Prognostic concordance index = 0.84 (95%CI: 0.59–0.95) for GFR < 60 and 0.55 (95%CI: 0.27–0.81) for GFR 60–89.DiscussionThe etiological fraction of death and prognostic concordance index associated to baseline GFR level increase significantly with decline of baseline GFR.ConclusionBaseline GFR seems to predict the six-year survival in African sub-Saharan patients treated for HIV.     

Factors associated with patient satisfaction with foot and ankle surgery in a large prospective study

BackgroundThere is minimal published research on outcomes and satisfaction with foot and ankle surgery.ObjectiveTo investigate patient-reported outcomes and satisfaction, and investigate which factors influence satisfaction at 9 months following foot or ankle surgery.MethodsProspective study of 671 adult patients having foot or ankle surgery. Pre-and post-surgery, patients self-completed MOXFQ, SF-36 and EQ-5D questionnaires. Using ratings to a satisfaction item, patients who were ‘very pleased’ with the outcome were compared with everyone else, using multiple logistic regression, regarding their pre-, peri- and post-operative characteristics.ResultsOf 628 eligible patients, 491 (73%) completed pre-and post-operative questionnaires. Following adjustment, satisfaction with surgery was influenced by patients’ perceptions of their foot/ankle's appearance (OR 0.12, 95% CIs 0.06–0.23, p < 0.001); wearable range of shoes (OR 0.36, 95% CIs 0.17–0.79, p = 0.01); continued foot/ankle pain (OR 0.06, 95% CIs 0.03–0.14, p < 0.001); impairment in Social-Interaction (MOXFQ SI scale) (OR 0.98, 95% CIs 0.96–0.99, p = 0.009). The final explanatory model explained 67% of the variance in patient satisfaction.ConclusionsFoot appearance, wearable shoe range, the (full) alleviation of pain and the ability/confidence to interact socially are crucial to peoples’ satisfaction with their foot or ankle surgery.     

The effect of Helicopter Emergency Medical Services on trauma patient mortality in the Netherlands

IntroductionObject of this study was to evaluate the effect of the Helicopter Emergency Medical Services (HEMS) on trauma patient mortality and the effect of prehospital time on the association between HEMS and mortality.Materials and methodsTrauma patients admitted to a level 1 trauma centre and treated on-scene by the HEMS and Emergency Medical Services (EMS) between 2003 and 2008 were included (n = 186). A control group treated by EMS only (n = 186) was created by matching on ISS, age and severe traumatic brain injury (TBI). Mortality was compared by calculating odds ratios (OR) and numbers needed to treat (NNT), with adjustment for prehospital coded Revised Trauma Score. The effect of prehospital time mortality was tested by a logistic regression. Analyses were made for patients with and without TBI.ResultsThe OR of early trauma fatality for the HEMS/EMS versus EMS-only groups was 0.8 for patients both with TBI (95% CI 0.4–1.7; NNT: 22) and without TBI (95% CI 0.2–3.3; NNT: 273). The risk of in-hospital mortality was non-significantly higher for patients with TBI in the HEMS/EMS group (OR = 1.3; 95% CI 0.6–2.7; NNT: ?15) compared to the EMS-only group and non-significantly lower for patients without TBI (OR = 0.9; 95% CI 0.3–2.5; NNT: 129). After adjustment for prehospital time, the risk of early trauma fatality for patients with TBI treated by the HEMS decreased (OR = 0.6; 95% CI 0.3–1.6). The risk of in-hospital mortality for these patients decreased from 1.3 to 0.8 (95% CI 0.4–2.0). The effect of the HEMS on patients without TBI did not change after adjustment for prehospital time.DiscussionHEMS treatment is associated with a non-significantly higher risk of in-hospital mortality for patients with TBI and a non-significantly lower risk for patients without TBI. This increased risk of mortality in TBI patients is attributable to the increased prehospital time. These results indicate that HEMS does not have a positive impact on survival.     

Medicoeconomic evaluation of hyaluronic acid for knee osteoarthritis in everyday practice: the MESSAGE study

IntroductionMedicoeconomic data on treatments for osteoarthritis are scant. We investigated the impact of hyaluronic acid therapy on the cost of management of knee osteoarthritis. Our primary objective was to compare medical costs (admissions, outpatient visits, investigations, and treatments) and non-medical costs (sick leaves and transportation) from the perspective of the national health insurance system during the 3 months before and the 6 months after three intraarticular injections of hyaluronic acid. Our secondary objective was to evaluate treatment benefits in terms of pain, function, and quality of life.MethodsObservational, multicenter, longitudinal, before-after study of the medical and economic effects of hyaluronic acid therapy for symptomatic knee osteoarthritis.ResultsOf the 296 assessable patients (mean age, 69 years; 30% with obesity; 65% women), only 5% of patients were withdrawn prematurely from the study. Significant improvements in the Lequesne index were found 3 and 6 months after treatment; the improvement was greater than 50% in over half the patients. Pain and quality-of-life scores improved significantly. Total cost of the disease decreased from €334 for the 3 pretreatment months to €295 and €233 for posttreatment months 1–3 and 4–6, respectively.ConclusionThe costs of knee osteoarthritis decreased during the 6 months after Suplasyn^® therapy, indicating that the cost of the medication was more than offset by the decreased need for other treatments. Concomitantly, clinical benefits were obtained. Under the conditions of everyday practice, hyaluronic acid may provide medical benefits at an acceptable cost.     

Thromboprophylaxis with enoxaparin for total knee replacement: An observational, retrospective and multicentre study comparing starting the treatment before and after the operation

ObjectiveThe low molecular weight heparins are the first option for the prophylaxis of venous thromboembolic disease in major orthopaedic surgery. The time of starting their administration is controversial. The aim of this study was to evaluate the efficacy and safety of enoxaparin in patients subjected to total knee replacement comparing the starting of it before and after the surgery.MethodsAn observational, retrospective and multicentre study of normal clinical practice to determine the incidence of symptomatic deep venous thrombosis and/or pulmonary thromboembolism in total knee replacement surgery. Thromboprophylaxis was normal practice in each centre. Patients were included if they received the first dose of 40 mg/24 h of enoxaparin either 12 h (± 2 h) before the surgery (G-PRE) or between 6 and 12 hours after the surgery (G-POST). The main safety objective was haemorrhage. A multivariate logistic regression analysis was performed to determine the real influence of each variable.ResultsData was collected from 2014 patients, of whom 1440 were included for the analysis of efficacy (782/1440, 54% of the G-PRE and 658/1440, 46% of the G-POST). The mean incidence of symptomatic thrombotic events was 1.67% (24/1440). The incidence of deep venous thrombosis in the G-PRE was 1.15% compared to 1.22% in the G-POST (P=.569 after multivariate analysis) and the incidence of pulmonary thromboembolism was 0.51 compared to 0.76%, respectively (P=.582 after multivariate analysis). A total of 1422 patients were included for the safety analysis. There was significant bleeding in 59/788 of the G-PRE and in 35/634 of the G-POST (7.49% compared to 5.52%, respectively, P=.138).ConclusionsThese results suggest that thromboprophylaxis with enoxaparin (40 mg/24 h sc) in patients subjected to total knee replacement surgery has a similar safety and effective profile when it is given 12 hours before the surgery or between 6 and 12 hours afterwards.     

Study on the findings of an immediate renal gammagraphy and its effect on the survival of a kidney graft

IntroductionWe assessed the effect of the findings of the renal gammagraphy (99mTc-DTPA) taken in the first 24 hours after the transplant in the survival of the kidney transplant.Materials and methodWe retrospectively studied 413 kidney transplants carried out between January 1994 and December 2008, with emphasis on normal gammagraphic findings or alterations in the vascular, parenchymal and excretory stages, as well as their effect on the survival of the graft.ResultsOf the 413 transplants, 44 (10.7%) presented alterations in the vascular stage, 256 (62%) in the parenchymal stage and 269 (65.1%) in the excretory stage. The mean follow-up of the entire group was 72.5 months (± 54.1 DE). The univariate analysis shows that the survival of the graft is significantly less in patients with alterations in the vascular stage (OR: 3; IC 95% 1.9 – 4.9 p < 0.001), in the excretory stage (OR: 2.5; IC 95% 1.5 - 4; p = <0.001) in the parenchymal stage (OR: 2.21; IC 95% 1.3-3.36; p = 0.001). The multivariate studies of the gammagraphic variables that affect the survival of the graft show that the presence of alterations in the vascular stage (OR: 3; IC 95% 1.9-4.9; p < 0.001) in the parenchymal stage (OR: 2; IC 95% 1.2-3.3; p = 0.005) are directly related to survival. This data is also confirmed by means of the actuarial survival analysis of the graft at 3 and 5 years.ConclusionsThe presence of alterations in the vascular stage and in the parenchymal stage of the renal gammagraphy immediately after the transplant are variables that affect the survival of the graft.     

Clinical outcomes of autogenous cancellous bone grafts obtained through the portal for tibial nailing

BackgroundThe purpose of this study is to introduce and review the clinical outcomes of a new technique for harvesting autogenous cancellous bone grafts in association with tibial intramedullary (IM) nailing.Materials and methodsWe retrospectively reviewed 21 patients who received autogenous cancellous bone grafts obtained from the entry portal of a tibial IM nail for fracture gaps, malalignment or nonunion in the lower extremities. All patients were scheduled to receive IM nailing or had already received IM nailing for the fixation of an ipsilateral tibia shaft fracture. A total of 33 patients who received only tibial IM nailing were selected as a control group. Through the follow-up, postoperative complications related to the bone harvest were monitored. Further by taking serial X-rays, radiographic changes of the donor site and the knee joint were closely observed. Knee pain (visual analogue scale (VAS)) and function (Lysholm knee score) were compared between the study group and the control group.ResultsAt the last follow-up, the average VAS in the study group was 1.28 (0–5), which was not significantly different from the control group (VAS: 1.36, range 0–7) (P = 0.985). The range of motion of the knee joint was similar in both groups, averaging 130.23° (range: 115–135°) and 131.36° (range: 115–135°), respectively. There was no significant difference in the Lysholm knee score between the study and control groups (P = 0.610). All patients exhibited complete fracture healing at an average of 6 months and no complications associated with the bone donor site were observed.ConclusionsBy using the new technique, autogenous cancellous bone grafting can be performed conveniently and safely to treat fracture gaps, malalignment or nonunion in the lower extremities without additional morbidity at the donor site.