Local infiltration analgesia in TKA patients reduces length of stay and postoperative pain scores

Numerous postoperative pain protocols exist for patients undergoing total knee arthroplasty (TKA). We compared the length of stay, early range of motion (ROM), and pain scores of a control group with a femoral nerve block to those of a group with femoral nerve block and local infiltration analgesia following TKA. In a consecutive series of patients undergoing primary TKA at a Veteran's Administration hospital, 40 patients (40 TKAs) who had local infiltration analgesia were compared to a historical group of 43 patients (43 TKAs) who had a long-acting femoral nerve block without local infiltration analgesia. Local infiltration analgesia consisted of intraoperative injection of 150 mL of 300 mg ropivacaine, 30 mg ketorolac, and 500 μg epinephrine using 50 mL into each of 3 areas: (1) posterior capsule, (2) medial and lateral capsule, and (3) anterior capsule and subcutaneous tissues. A 17-gauge intra-articular catheter was used to inject an additional 100 mg of ropivacaine on postoperative day 1. The control group had a single-shot femoral nerve block using 150 mg of ropivacaine with epinephrine. Mean length of stay for the local infiltration analgesia group compared to controls was 3.2±1.4 days vs 3.8±1.6 days, respectively (P=.03). No significant differences existed in average ROM (6 weeks), discharge hematocrit, transfusions, and temperature. Mean pain scores were lower in the local infiltration analgesia group on postoperative day 1 (P=.04), but not on postoperative day 2 or 3. Maximum visual analog scale scores (P<.01) were reduced in the local infiltration analgesia group. Our early experience with local infiltration analgesia demonstrated a significantly reduced length of stay due to decreased postoperative pain.     

Endarterectomy and surgical angioplasty without cardiopulmonary bypass

Surgical angioplasty for ostial stenosis of the major coronary arteries is a well-established treatment modality. Management of discrete stenoses of distal coronary arteries in the presence of mild proximal disease is a challenging task. Percutaneous intervention or grafting beyond the diseased segment may be limited by size of the target vessel, whereas endarterectomy followed by graft placement may result in graft occlusion due to competitive native flow. Patch angioplasty with or without endarterectomy is an effective option in this setting, which can be performed without cardiopulmonary bypass in the appropriate group of patients. A patient with triple vessel coronary artery disease and a discrete lesion in the posterior descending artery underwent off-pump endarterectomy with vein patch angioplasty in combination with bypass grafting to left anterior descending and obtuse marginal arteries. Operative technique and intraoperative strategies are discussed.     

Peripheral mechanisms of erectile dysfunction in a rat model of chronic cocaine use

OBJECTIVE: To evaluate the peripheral mechanisms of erectile dysfunction (ED) in a rat model of triple-binge cocaine administration. METHODS: Adult male Sprague-Dawley rats (n=24) were divided into two groups: group 1, control rats receiving vehicle (saline); group 2, rats receiving binge cocaine injections. After completion of triple-binge cocaine or saline injections, both groups underwent an in vivo, neurogenic-mediated erectile response protocol to assess intracavernosal pressure (ICP). Penile endothelin-A and -B receptors (ET(A)R and ET(B)R), plasma levels of big endothelin-1 (big-ET-1), and endothelial nitric oxide synthase (eNOS) protein expression were assessed. To analyze nitric oxide (NO) production, we measured plasma nitrate-nitrite levels and quantitated myeloperoxidase (MPO) activity in cavernosal tissues to determine reactive oxygen species generation. Endothelium-dependent and -independent relaxation responses were evaluated in vitro. Data were analyzed with Student t test. RESULTS: Triple-binge cocaine administration caused significantly decreased erectile responses as measured by ICP in vivo. Plasma big-ET-1 levels were significantly increased in the triple-binge cocaine treatment group compared with control animals. In the penis, triple-binge cocaine administration significantly increased ET(A)R expression compared with saline controls, while ET(B)R expression was not altered. Cocaine-treated rats had significantly decreased eNOS expression and NO production. The activity of tissue MPO was significantly increased in the cocaine group compared with control rats. Organ bath studies demonstrated that triple-binge cocaine resulted in a 64% reduction in maximal relaxation compared with the control group. CONCLUSION: This study demonstrates that triple-binge cocaine administration significantly reduces erectile function in rats. The pathophysiologic mechanisms that are likely involved include increased plasma big-ET-1 levels, increased penile ET(A)R expression, increased penile MPO activity, and reduced penile eNOS expression.     

Is a fall in baseline heart rate a reliable predictor of a successful single shot caudal epidural in children?

BACKGROUND: This study was designed to investigate whether a fall in heart rate (HR) with injection of local anesthetic into the caudal space can be used as a predictor of correct needle placement. METHODS: Two hundred and twenty pediatric patients undergoing infraumbilical surgery were recruited to the study. After induction of general anesthesia, baseline HR was recorded and caudal block was performed using 0.75-1 ml x kg(-1) 0.25% bupivacaine, which was injected at a rate of 1 ml x 3 s(-1). The change in HR while injecting an initial 0.2 ml x kg(-1) of drug and during total drug injection was recorded. HR reduction of > or = 3 b x min(-1) was considered a positive test for correct needle placement. The success of block was judged by HR response to skin incision, endtidal halothane concentration required for maintenance of anesthesia and postoperative pain scores. RESULTS: Caudal block was successful in 209/220 (95%) patients. Mean HR following the initial drug injection (111 +/- 17.7, P < 0.01) and entire drug injection (108.8 +/- 17.2, P < 0.01) was significantly lower than baseline (116.2 +/- 17.5). HR reduction of > or = 3 b x min(-1) was present in 190/209 and 199/209 successful block following initial drug injection and total drug injection respectively. The analysis of study data showed that a fall in HR is a predictor of successful caudal block, with a sensitivity of 90.9%, specificity of 100% and a positive predictive value of 100% after initial injection of local anesthetic. CONCLUSIONS: We conclude that decrease in HR with drug injection is a simple, objective and reliable test to predict success of caudal block.     

Endoscopic versus open carpal tunnel release: A short-term comparative study

Objective:

To compare the results of endoscopic carpal tunnel release (CTR) with open CTR in patients with idiopathic Carpal tunnel syndrome (CTS).

Materials and Methods:

Seventy-one patients with CTS were enrolled in a prospective randomized study from May 2003 to December 2005. All patients had clinical signs or symptoms and electro-diagnostic findings consistent with carpal tunnel syndrome and had not responded to nonoperative management. Sixty-one cases were available for follow-up. Endoscopic CTR was performed in 30 CTS patients and open CTR was performed in 31 wrists (30 patients). Various parameters were evaluated, including each patient''s symptom amelioration, complications, operation time, time needed to resume normal lifestyle and the frequency of revision surgery. All the patients were followed up for six months.

Results:

During the initial months after surgery, the patients treated with the endoscopic method were better symptomatically and functionally. Local wound problems in terms of scarring or scar tenderness were significantly more pronounced in patients undergoing open CTR compared to patients undergoing endoscopic CTR. Average delay to return to normal activity was appreciably less in group undergoing endoscopic CTR. No significant difference was observed between the endoscopic CTR group and open CTR group in regard to symptom amelioration, electromyographic testing and complications at the end of six months.

Conclusion:

Short-term results were better with the endoscopic method as there was no scar tenderness. Results at six months were comparable in both groups.     

Unreamed interlocking nailing in open fractures of tibia

PURPOSE: To assess the clinical outcome of unreamed intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the unreamed intramedullary nailing. METHODS: Between June 1999 and May 2000, a total of 60 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at Safdarjung Hospital, New Delhi, India. Records of 56 patients (4 women and 52 men) were available for study. Only injuries associated with the tibial shaft were included. Traffic accidents were the cause of fractures in all patients. All fractures were classified according to Gustilo and Anderson system for open fractures. There were 30 (53.6%) type-I, 18 (32.1%) type-II, 4 (7.1%) type-IIIA, and 4 (7.1%) type-IIIB fractures. After thorough debridement under anaesthesia, an unreamed interlocking nail was inserted with assistance by an image intensifier. All nails were statically locked with one screw each proximally and distally. RESULTS: The patients were followed up for a mean period of 20 months (range, 18-24 months) and were evaluated according to the modified Ketenjian's criteria. Results were good to excellent in 85.8% cases, and poor in 10.7% cases. Only 2 of 8 patients with type-III fractures had good results. Two of 4 type-IIIA and all 4 type-IIIB fractures had chronic osteomyelitis. Of 56 patients, 6 had early infection, 6 had delayed union, 6 had infected non-union, 2 had nail breakage, 8 had screw breakage, and 10 had anterior knee pain. CONCLUSION: Unreamed interlocking tibial nailing can be safely used for type-I and type-II open injuries even with delayed presentation. Use of unreamed nailing in those type-III fractures with delayed presentation was not recommended, because of high incidence of complications.     

Laparoscopic inguinal hernia repair: transabdominal preperitoneal (TAPP) versus totally extraperitoneal (TEP) approach: a prospective randomized controlled trial

Background  

Minimal access approaches to inguinal hernia repair have added to the ongoing debate over the “best groin hernia repair.” The present prospective randomized controlled trial was done to compare the totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) techniques of laparoscopic inguinal hernia repair.     

Macroscopic Quality Control Improves the Reliability of Blue Dye–Only Sentinel Lymph Node Biopsy in Breast Cancer

Background: One of the problems of sentinel lymph node (SLN) biopsy is the risk of false negatives. At the Institut Curie, to reduce the false-negative rate, we have developed a histological quality control of the SLN performed by blue dye alone, which consists of verification of the SLN blue stain by the pathologist.Methods: A total of 324 patients underwent an SLN biopsy procedure with patent blue dye only followed by an immediate axillary dissection. Initially, SLNs were checked to ensure that they were blue by macroscopic examination. Finally, a search for immunohistochemistry micrometastasis was performed.Results: In 277 (85.5%) of 324 patients, an SLN was identified by the surgeon. After standard examination, the false-negative rate was 11.1% (10 of 90). After macroscopic checking of the 197 negative SLNs, 167 of the 197 were confirmed blue, and there were 5 false negatives, which brought the false-negative rate down to 5.6% (5 of 90). Sixty SLNs out of the 167 confirmed blue SLNs were then proved to be immunohistochemically micrometastatic, and there were 3 false negatives, giving a final false-negative rate of 2.2% (2 of 90; P = .002).Conclusions: In this series, the procedure of pathologic analysis of the SLN has resulted in a significant reduction of the false-negative rate.