Regional blocks in orthopaedics

Effective postoperative pain management plays a significant role in decreasing hospital stay and has a positive effect on functional recovery and patient satisfaction. Orthopaedic surgery is an expanding surgical specialty with a potentially difficult patient population. Regional anaesthesia is becoming increasingly popular as it offers several advantages over general anaesthesia. The aim of analgesic protocols is not only to reduce pain intensity but also to decrease the incidence of side effects from analgesic agents and to improve patient comfort. Moreover, adequate pain control is a prerequisite for rehabilitation programmes to accelerate functional recovery and may have economic benefits. Recently there has been resurgence in the use of regional anaesthesia with advanced techniques for nerve localization and visualization of needle and local anaesthetic spread. The use of peripheral nerve blocks has been associated with earlier discharge in ambulatory orthopaedic surgery when compared to general anaesthesia and neuraxial blockade.     

Regional vs general anaesthesia in orthopaedics

It becomes difficult to develop a cogent argument (from the literature regarding patient outcome) for regional anaesthesia in preference to general anaesthesia for orthopaedic surgery. For deep venous thrombosis, it may be that the attendant medical care of the patient should be altered rather than the anaesthetic technique. Advantages of regional anaesthesia may be short-lived, and overwhelmed by the myriad of other factors coming into play, as with blood loss and perioperative delirium. Even nausea and vomiting are not clearly reduced by the use of the techniques. The persistence of the belief in the superiority of regional anaesthesia may represent a case of our unwillingness to “abandon a perfectly good theory simply because it is wrong,” or it may be that we simply have not asked the appropriate question to elucidate a common impression. This latter remains a challenge. Il appara?t difficile de produire un argument convaincant (à partir de la littérature faisant état du pronostic à long terme) qui favoriserait l’anesthésie régionale sur la générale en chirurgie orthopédique. En ce qui concerne la thrombose veineuse profonde, c’est l’attention médicale portée au patient qui doit être modifiée plut?t que la technique anesthésique. Les avantages de l’anesthésie régionale pourraient ne pas faire long feu et subir l’inondation de la multitude des autres facteurs reconnus, aussi bien en ce qui concerne la perte sanguine que le délire postopératoire. Même les nausées et vomissements ne sont pas réduits de fa?on évidente par l’usage des techniques régionales. La persistence de cette prétendue supériorité de l’anesthésie régjonale peut refléter le dicton qui énonce que les mythes ont la vie dure, ou encore résulter du fait qu’on ne s’est pas encore posé les bonnes questions qui nous permettraient d’élucider une impression clinique répandue. La dernière question demeure un défi.     

Regional vs general anaesthesia in orthopaedics

Canadian Journal of Anesthesia/Journal canadien d'anesthésie - It becomes difficult to develop a cogent argument (from the literature regarding patient outcome) for regional anaesthesia in...     

Regional blocks for cesarean section

Recent researches in the field of regional anesthesia for cesarean section have focused on spinal anesthesia, including prophylaxis of maternal hypotension, the use of opioids to improve intra- and postoperative analgesia and the use of ropivacaine.     

Smartphones in orthopaedics

With the introduction of the European Working Time Directive, surgical trainees are facing limited training opportunities and doctors are required to maximise their training opportunities. Smartphone sales have been rapidly increasing over the last five years and can be used as a training tool for the orthopaedic trainee and surgeon. Common uses include applications (AO, eLogbook and PubMed), Ebooks, online Logbooks, Guidelines and surgical techniques. In addition, smartphones can be used to immediately complete work-based assessments, in the absence of computers, hopefully increasing completion rates and reliability. Some journals now provide podcasts and video tutorials which may be accessed on smartphones, which is useful for higher examinations. Smartphones can also be used in the clinical setting to take photographs of wounds. Smartphones are enjoying increased uptake and application in the workplace and we review their use for orthopaedic surgeons and trainees to allow them to make the most out of their training opportunities.     

Teleradiology in orthopaedics

Teleradiology is a means of electronically transmitting radiographic image files from one location to another. Technologic advances in digital imaging, telecommunications, digital storage, and viewing technologies have made teleradiology readily available and reasonably affordable. The five components of a teleradiology system include: a sending station, a transmission network, a storage device, a viewing station and, a software package. The advantage of teleradiology is the mobility of digital images. In contrast to plain radiographs that only can be seen in one location at a time, multiple persons who are at different locations can view digital images simultaneously. When applied to orthopaedic trauma applications, when the consulting orthopaedist is at a remote location from the patient, teleradiology has been shown to improve diagnostic accuracy, disposition planning of patients from emergency departments or outlying hospitals, and planning of surgical procedures. These systems also improve the comfort level of consulting orthopaedic surgeons and potentially limit the risk of litigation for incorrect diagnosis. The quality, convenience, and effectiveness of teleradiology systems should improve as the technologies continue to mature. Having radiographic images available on handheld devices, such as cell phones, is likely to be a reality in the near future.     

Molecular biology in orthopaedics: the advent of molecular orthopaedics

Molecular biology is the study, at the molecular level, of how genetic information is stored, inherited, and expressed and how it influences the structure and function of cells. Although molecular biology approaches have been used for decades in orthopaedic research, they are only now beginning to influence clinical practice. A variety of sophisticated techniques permit rapid and affordable DNA sequencing, gene expression profiling, gene cloning, gene manipulation, gene transfer, recombinant protein production, and other technologies of enormous biomedical importance. Success in genomics has spawned additional ambitious endeavors, including proteomics, pharmacogenetics, and bioinformatics. These techniques are providing new diagnostic, staging, prognostic, and therapeutic opportunities in all areas of medicine, including orthopaedics. With the use of molecular criteria, treatment of the orthopaedic patient may become more individualized, and greater emphasis will be placed on preventative strategies based on the patient's genetic makeup. Both surgical and nonsurgical decisions will increasingly accommodate molecular criteria.     

数字骨科学:一门骨科学新分支的萌生

美国可视人计划（1989）的出现推动了数字人和医学图像研究的进程。数字人研究是现代计算机信息技术与医学等学科相互结合的前沿性交叉项目，对科技发展有着深远意义。数字化技术可以利用动态三维图像对传统二维医学图像进行补充，用连续断层图像进行三维重建，可以精确地显示生物组织复杂的三维结构，并可进行任意旋转、剖切等观察和操作，可以对重建的三维结构进行测量获得长度、面积、     

Diversity in orthopaedics.

There is little doubt that women, African Americans, and Hispanics, have fewer opportunities to enter, or once in, to become contributing members of orthopaedic programs in the United States. The expressed reasons for this by faculty members sometimes sound reasonable, but on analysis all are spurious. It is the responsibility of the chief of service and the faculty members to change this pattern and offer all individuals equal opportunity and treat them identically to anyone in the program or on the faculty. Some guidelines are provided.     

Gene therapy in orthopaedics

Impressive advances in our knowledge of the molecular genetic basis of skeletal disorders and fracture healing have led to the development of novel therapeutics based on ectopic expression of one or more genes in patient cells that can influence repair or regenerative processes in bone. Gene therapy is an attractive new approach to the treatment of bone disorders. Orthopaedics has become one of the most promising areas of research into gene therapy. This is because many potential orthopaedic targets for gene therapy, unlike traditional targets such as cancer and severe genetic disorders, neither present difficult delivery problems nor require prolonged periods of gene expression. Gene therapy offers new possibilities for the clinical management of orthopaedic conditions that are difficult to treat by traditional surgical or medical means. Impaired bone healing, need for extensive bone formation, cartilage repair and metabolic bone diseases are all conditions where alterations of the signalling peptides involved may provide cure or improvement. In orthopaedic oncology, gene therapy may achieve induction of tumour necrosis and increased tumour sensitivity to chemotherapy. An increasing amount of evidence indicates that gene transfer can aid the repair of articular cartilage, menisci, intervertebral disks, ligaments and tendons. These developments have the potential to transform many areas of musculoskeletal care, leading to treatments that are less invasive, more effective and less expensive than existing modalities.     

Classification systems in orthopaedics

Classification systems help orthopaedic surgeons characterize a problem, suggest a potential prognosis, and offer guidance in determining the optimal treatment method for a particular condition. Classification systems also play a key role in the reporting of clinical and epidemiologic data, allowing uniform comparison and documentation of like conditions. A useful classification system is reliable and valid. Although the measurement of validity is often difficult and sometimes impractical, reliability-as summarized by intraobserver and interobserver reliability-is easy to measure and should serve as a minimum standard for validation. Reliability is measured by the kappa value, which distinguishes true agreement of various observations from agreement due to chance alone. Some commonly used classifications of musculoskeletal conditions have not proved to be reliable when critically evaluated.     

Decision analysis in orthopaedics

Orthopaedic surgeons are faced with an ever-growing amount of clinical information from which they are required to make treatment decisions. Many of these decisions can be approached with relative certainty. However, there are many situations where the optimal decision is less clear. These treatment decisions will have competing risks, benefits, or costs. Decision analysis is one method to critically evaluate alternative treatment options with multiple potential outcomes. This method of decision making can be extremely valuable because of the growing number of treatment alternatives, and to the ever-increasing complexity of medical scenarios.     

Vascular microsurgery in orthopaedics

Summary Three applications of free vascularised bone grafts are described. Free fibular grafts have been performed in 19 cases of avascular necrosis of the femoral head. The grafts are placed along the anterior femoral neck and into the femoral head with a microvascular anastomosis between the nutrient vessels of the fibula and the anterior circumflex pedicle of the hip. The operative technique is described but the post-operative follow-up is still too short to draw any definite conclusions.This operation has been performed in young patients in whom the only alternative would be a total hip replacement.Free vascularised transfers of iliac crest bone are described for bone defects such as infected nonunions of the tibia with soft tissue and bony loss. Free vascularised fibula grafts have also been employed with cancellous grafting for cystic defects such as fibrous dysplasia and large bone cysts.The use of free vascularised fibula grafts is also described in four cases of congenital pseudarthrosis of the tibia.

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Résumé Les auteurs présentent une technique originale pour le traitement des nécroses de la tête fémorale. La tête fémorale est luxée et par un volet cartilagineux, la nécrose est excisée et remplacée par de l'os spongieux. Une diaphyse péronière est placée à la face antérieure du col et fixée dans le spongieux de la tête fémorale. Ce péroné est revascularisé par des anastomoses micro-chirurgicales.A propos de 19 cas opérés, les auteurs décrivent la technique et les premiers résultats qui sont encore précoces. Il s'agit là d'une tentative thérapeutique dont nous ne connaîtrons les résultats que dans quelques années.

     

Geriatric orthopaedics

Summary The aggressive attack on the orthopaedic ailments of the elderly is well rewarded by the results. That old people are going to die sooner rather than later is recognised not only by the patient but sometimes, with too much emphasis, by the surgeon who is then fearful of operating. Many old people prefer to take a reasonable chance to achieve a happy and satisfactory quality of life by having a major operation than to linger on in pain, unhappiness, and without independence. To deny these old people an operation may well deny them hope and condemn them to an existence not worth living.

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Résumé L'audace chirurgicale des maladies orthopédiques du vieillard est amplement récompensée par les résultats obtenus.Le fait que pour le vieillard, la mort soit proche, constitue pour le patient, mais également pour le chirurgien, un frein à l'intervention.La plupart des gens âgés préfèrent prendre le risque raisonnable d'une intervention majeure, de façon à poursuivre une vie heureuse, plutôt que de souffrir et de se sentir dépendant sur le plan social.Refuser aux vieillards une intervention, c'est leur refuser aussi l'espoir et les astreindre à une vie sans horizon.