Aims. Cervical spondylosis is often accompanied by dizziness. It has recently been shown that the ingrowth of Ruffini corpuscles into diseased cervical discs may be related to cervicogenic dizziness. In order to evaluate whether cervicogenic dizziness stems from the diseased cervical disc, we performed a prospective cohort study to assess the effectiveness of anterior cervical discectomy and fusion on the relief of dizziness. Patients and Methods. Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain. Results. There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group. Conclusion. This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis. Cite this article: Bone Joint J 2018;100-B:81–7

Aims. The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD. Methods. This retrospective cohort study followed pre-selected patients for SDD THA from 1 August 2018 to 31 December 2020. Inclusion criteria were patients undergoing unilateral THA with appropriate social support, age 18 to 75 years, and BMI < 37 kg/m. 2. Patients with opioid dependence, coronary artery disease, and valvular heart disease were excluded. Demographics, comorbidities, and perioperative data were collected from the electronic medical records. Possible risk factors for failed SDD were identified using multivariate logistic regression. Results. In all, 278 patients were identified with a mean age of 57.1 years (SD 8.1) and a mean BMI of 27.3 kg/m. 2. (SD 4.5). A total of 96 patients failed SDD, with the most common reasons being failure to clear physical therapy (26%), dizziness (22%), and postoperative nausea and vomiting (11%). Risk factors associated with failed SDD included smokers (odds ratio (OR) 6.24; p = 0.009), a maximum postoperative pain score > 8 (OR 4.76; p = 0.004), and procedures starting after 11 am (OR 2.28; p = 0.015). A higher postoperative tolerable pain goal (numerical rating scale 4 to 10) was found to be associated with successful SDD (OR 2.7; p = 0.001). Age, BMI, surgical approach, American Society of Anesthesiologists grade, and anaesthesia type were not associated with failed SDD. Conclusion. SDD is a safe and viable option for pre-selected patients interested in rapid recovery THA. The most common causes for failure to launch were failing to clear physical thereapy and patient symptomatology. Risk factors associated with failed SSD highlight the importance of preoperative counselling regarding smoking cessation and postoperative pain to set reasonable expectations. Future interventions should aim to improve patient postoperative mobilization, pain control, and decrease symptomatology. Cite this article: Bone Jt Open 2022;3(9):684–691

Abstract. Aim. This study was aimed to look into factors responsible for delayed mobilization after lower limb arthroplasty and effect on length of stay. Methods. It is an observational study conducted at Kings Mill Hospital from August to October 2021. All patients undergoing primary knee or hip arthroplasty were included in the study, while patients with revision surgeries were excluded. A proforma was designed to record demographics and different variables including medications, type of anaesthesia, orthostatic hypotension, dizziness, preop and post op pain score, fall in haemoglobin, analgesia and length of stay. Patients were assessed on day one and data was recorded in the proforma. Data was analysed using SPSS. Results. There were 60 patients (32 females and 28 males) which were included in the study. Mean age was 69.62 years. Thirty patients underwent TKA while in the rest of 30 patients THA was done. Fifty patients were mobilized on day one while 10 patients failed to mobilise. Out of different variables assessed orthostatic hypotension, dizziness, pre mobilization pain score and pain score during mobilization were found to be significant. Mean length of stay was longer in patients with delayed mobilization (P=0.018). Conclusion. Pain, dizziness and orthostatic hypotension were independent factors affecting mobilization after lower limb arthroplasty and indirectly increasing the length of stay

Background. Adequate pain management is mandatory for patients' early rehabilitation and improvement of outcome after total knee arthroplasty (TKA). Conventional pain management, consisted of mainly opioids, has some adverse effects such as dizziness and nausea. Motor blockade occasionally resulted from epidural analgesics. A novel multimodal analgesic strategy with peripheral nerve block, peri-articular injection (PAI) and intravenous patient controlled analgesia (IVPCA) were utilized for our patients receiving TKA. In this study, we compared the clinical efficacy and adverse effects in the group of multimodal analgesia (MA) or epidural analgesia alone. Methods. One hundred and eighteen patients undergoing TKA with spinal anesthesia were enrolled. Patients of TKA received either our protocol of multimodal analgesia or patient controlled epidural analgesia (PCEA) alone. MA included ultrasound guided nerve block in femoral and obturator nerves before spinal anesthesia, and PAI mixed with NSAID, morphine, ropivacaine and epinephrine, as well as IVPCA after surgeries. The analgesic effect with numeric rating scale (NRS) and occurrence of adverse effects, including motor blockade, numbness, postoperative nausea/vomiting (PONV), and dizziness were recorded for all patients. Results. Thirty-one patients received MA, and eighty-seven patients received PCEA. No significant difference of NRS in MA and PCEA group within 24 hours after surgery either in rest (0.2 ± 1 compared with 0.22 ± 0.98; p = 0.930) or motion (0.40 ± 1.56 compared with 0.31± 1.23; p = 0.764). MA group sustained lesser motor blockade than PCEA (6.45% compared with 22.98%; p = 0.028) beyond 24 hours after surgery. The occurrence of numbness is lower in MA group (18.52%) compared with PCEA group(43.33%) (p=0.031). No statistic difference of PONV and dizziness is noted between two groups. However, there is a trend that lesser PONV and dizziness occurred in MA group than PCEA group. Conclusion. TKA patients receiving either MA or PCEA have adequate analgesic efficacy after surgeries. MA group has a lower incidence of motor blockade and PONV than PCEA. This multimodal analgesia proposed here has shown patients' safety and improved pain control after TKA, decreased narcotics use and their associated side effects. Besides, lesser motor blockade and adequate pain relief may encourage patient's early rehabilitation

Background. Immersive virtual reality (VR) demonstrates potential benefits in patients with chronic low back pain (CLBP). However, few studies have investigated the feasibility and the acceptability of introducing immersive VR for use with patients with CLBP and in the Kingdom of Saudi Arabia (KSA). Aim. To investigate immersive VR's feasibility, tolerability, and acceptability as a rehabilitation intervention for adult patients with CLBP and explore the views of relevant Health Care Practitioners (HCPs) in the KSA. Methodology and Methods. A multi-centre, mixed-methods, explanatory sequential design was adopted to test immersive VR's feasibility, tolerability, and acceptability. An uncontrolled feasibility trial was conducted. The immersive VR intervention involved a training session followed by three sessions over one week using commercially available hardware and software. Feasibility outcomes were collected from patients immediately post-intervention. Patients and HCPs were recruited for semi-structured interviews. Results. Thirty-three patients and three HCPs were recruited. The feasibility a priori criteria were met for recruitment, retention, dropout, completeness of questionnaire data, treatment compliance and fidelity. Adverse events included one who reported aggravation of tinnitus, whereas two experienced dizziness. Qualitative data suggested that entertainment and motivation were key enablers. Barriers included technological capability and HCPs’ perceptions that immersive VR was time-consuming. Conclusion. The results suggested that immersive VR was feasible, acceptable, and tolerable among patients with CLBP and HCPs in clinical settings in the KSA. Further research focusing on the effectiveness is warranted in this field. Conflicts of Interest. None. Sources of Funding. None. Trial registration number. ISRCTN14434517

The development and implementation of Enhanced Recovery After Surgery (ERAS) protocols are of particular interest in elective orthopaedics due to clinical benefits and cost effectiveness. The Wycombe Arthroplasty Rapid-Recovery Pathway (WARP) was designed to streamline hip and knee joint arthroplasty to reduce time spent in hospital whilst optimising outcomes in an NHS District General Hospital. 966 patients were admitted to Wycombe General Hospital for primary elective joint replacement (60 UKR, 446 THR, 460 TKR) during the period 1st September 2020 to 31st September 2022. The WARP pathway was used for 357 (37%) patients (32 UKR, 155 THR, 170 TKR) and the standard “non-WARP” pathway was used for 609 (63%) patients (28 UKR 291 THR, 290 TKR). Data was collected on length of stay, time of mobilisation, number of physiotherapy sessions, and inpatient morbidity. Average length of stay following UKR was 0.75 days for WARP vs 2.96 for non-WARP patients, following THR was 2.17 days for WARP vs 4.17 for non-WARP patients, following TKR was 3.4 days for WARP vs 3.92 for non-WARP patients. Day-0 mobilisation after UKR was achieved in 97% of WARP vs 12% of non-WARP patients, after THR in 43% of WARP vs 14% of non-WARP patients, after TKR in 33% of WARP vs 11% of non-WARP patients. Same-day discharge was achieved in the WARP cohort in 63% of UKR, 10% of THR, 2% of TKR patients. There were no same-day discharges in the non-WARP cohort. Complications delaying mobilisation (pain, nausea/vomiting, dizziness/low BP) were identified in 8.4% of WARP vs 25% of non-WARP patients. Our cohort study shows that the initiation of WARP Rapid Recovery pathway for joint arthroplasty decreased the average length of stay after UKR by 2.21 days, after THR by 2 days, after TKR by 0.52 days. Time to first mobilisation was decreased significantly by increased rates of same-day mobilisation and reduced rates of postoperative anaesthetic-related complications

Aims. The aim of this study was to report our experience at 3.5 years with outpatient total hip arthroplasty (THA). Methods. In this prospective cohort study, we included all patients who were planned to receive primary THA through the anterior approach between 1 April 2014 and 1 October 2017. Patient-related data and surgical information were recorded. Patient reported outcome measures (PROMs) related to the hip and an anchor question were taken preoperatively, at six weeks, three months, and one year after surgery. All complications, readmissions, and reoperations were registered. Results. Of the 647 THA patients who had surgery in this period through the anterior approach, 257 patients (39.7%) met the inclusion criteria and were scheduled for THA in an outpatient setting. Of these, 40 patients (15.6%) were admitted to the hospital, mainly because of postoperative nausea and/or dizziness. All other 217 patients were able to go home on the day of surgery. All hip-related PROMs improved significantly up to 12 months after surgery, compared with the scores before surgery. There were three readmissions and two reoperations in the outpatient cohort. There were no complications related to the outpatient THA protocol. Conclusion. These study results confirm that outpatient THA can be performed safe and successfully in a selected group of patients, with satisfying results up to one year postoperatively, and without outpatient-related complications, readmissions, and reoperations. Cite this article: Bone Joint J 2020;102-B(1):82–89

Introduction and Objective. Knee osteoarthritis (KOA) is a frequent disease for which therapeutic possibilities are limited. In current recommendations, the first-line analgesic is acetaminophen. However, low efficacy of acetaminophen, frequently leads to the use of weak opioids (WO) despite their poor tolerance, especially in elderly patients. The primary objective was to compare the analgesic efficacy and safety of a new wearable transcutaneous electrical nerve stimulation (W-TENS) to weak opioids (WO) in the treatment of moderate to severe, nociceptive, chronic pain in knee osteoarthritis patients. Materials and Methods. ArthroTENS study is a phase 3, non-inferiority, multicentric, prospective, randomized, single-blinded for primary efficacy outcome, controlled, in 2-parallel groups, clinical study comparing W-TENS versus WO over a 3-month controlled period with an additional, optional, non-controlled, 3-month follow-up for patients in W-TENS group. The co-primary outcome was KOA pain intensity (PI) at month 3 and the number of adverse events (AEs) over 3 months. Results. The non-inferiority of W-TENS was demonstrated in both the PP and ITT populations. At M3, PI in PP population was 3.87 (2.12) compared to 4.66 (2.37) (delta: −0.79 (0.44); 95% CI (−1.65; 0.08)) in W-TENS and WO groups, respectively. Since the absolute value of the 95% CI of the between-treatments mean PI difference [−1.71, – 0.12] was above 0 in ITT set, the planned superiority analysis was performed, demonstrating that W-TENS was significantly superior to WO at M3 (P=0.0124). At M1 and M3, the W-TENS group reached the absolute minimal clinically important difference (MCID) for an analgesic (1.8 (2.1) and 2.1 (2.3), respectively), corresponding to a 20 mm reduction in PI (interquartile range: 15–30) on a 0–100 mm visual analogic scale – i.e. 2 points on a numerical rating scale – which equates to “much better”. Conversely, in the WO group, a 0.5 (1.8) and a 1.1 (2.1) reduction in PI were observed at M1 and M3, respectively, while a 1-point reduction in PI is required to be considered as a “slightly better” improvement. In WO group, AEs were the common systemic AEs reported with WO (nausea, constipation, drowsiness, dizziness, pruritus, vomiting, dry mouth). AEs in W-TENS group were local, such as local cutaneous reaction (erythema). Thirty-nine (70.9%) patients wished to extend W-TENS treatment for 3 additional months. Only one patient discontinued this additional period and results were maintained at M6. Conclusions. W-TENS was more effective and better tolerated than WO in the treatment of nociceptive KOA chronic pain and could represent an interesting non-pharmacological alternative to WO

Aims. Currently, there is little information about the need for peri-operative blood transfusion in patients undergoing shoulder arthroplasty. . The purpose of this study was to identify the rate of transfusion and its predisposing factors, and to establish a blood conservation strategy. . Methods. We identified all patients who had undergone shoulder arthroplasty at our hospital between 1 January 2011 and 31 December 2013. The rate of transfusion was determined from the patient’s records. While there were exceptions, patients typically underwent transfusion if they had a level of haemoglobin of < 7.5 g/dl if asymptomatic, < 9.0 g/dl if they had a significant cardiac history or symptoms of dizziness or light headedness. . Multivariable regression analysis was undertaken to identify predictors of transfusion. High- and low-risk cohorts for transfusion were identified from a receiver operating characteristic (ROC) curve. Results. Of 1174 shoulder arthroplasties performed on 1081 patients, 53 cases (4.5%) required transfusion post-operatively. Predictors of blood transfusion were a lower pre-operative haematocrit (p < 0.001) and shoulder arthroplasty undertaken for post-traumatic arthritis (p < 0.001). ROC analysis identified pre-operative haematocrit of 39.6% as a 90% sensitivity cut-off for transfusion. In total 48 of the 436 (11%) shoulder arthroplasties with a pre-operative haematocrit < 39.6% needed transfusion compared with five of the 738 (0.70%) shoulder arthroplasties with a haematocrit above this level. . Discussion . We found that transfusion was needed less frequently than previously described for shoulder arthroplasty. Patients with a pre-operative haematocrit < 39.6% should be advised that there is an increased risk for blood transfusion, while those with a haematocrit above this level are unlikely to require transfusion. . Take home message: The rate of transfusion after shoulder arthroplasty is under 5%, and those with a pre-operative haematocrit greater than or equal to 39.6% have a very low likelihood (< 1%) of requiring a transfusion. Cite this article: Bone Joint J 2016;98-B:224–8

Purpose of the study. The aims of the study were to explore the experiences of sciatica sufferers, their perceptions of physiotherapy and healthcare service provision. Methods. This was the qualitative element of a mixed methods study investigating the feasibility of early physiotherapy for sciatica. Participants in the pilot trial consented to take part in semi-structured interviews before and after they had undertaken an individualised physiotherapy programme. Data from the interviews was examined line by line using a thematic analysis approach with key themes and sub-themes emerging. Results. Thirty-three participants were recruited and a total of 45 interviews being carried out. 7 central themes and 17 sub-themes were generated from thematic analysis. The first-line treatment administered to all participants by their G.P was a combination of analgesia. The drugs used included paracetamol, ibuprofen, nefopam, diclofenac, tramadol, morphine, diazepam and baclofen. Neuropathic pain modulating medication such as amitriptyline, gabapentin or pregabalin was widely used. Participants reported that medication simply didn't provide sufficient pain relief at a dose where side-effects were acceptable. Twenty-four interviewees described the negative side-effects of the drugs including nausea, dizziness, confusion, constipation, drowsiness, impotence and bloating. Furthermore, participants were concerned about their ability to carry out normal day to day tasks such as childcare, work and driving due to the side-effects of the drugs. Conclusion. Sciatica can be all encompassing, with severe pain and disability. A range of medication is commonly used for pain relief. The results from this study suggest that the drugs don't provide significant pain relief without deleterious side-effects in some patients. No conflicts of interest for any authors. Sources of funding: MR is the recipient of a HEE/NIHR Clinical Doctoral Research Fellowship which funded the study

INTRODUCTION. In recent years, there has been a shift toward outpatient and short-stay protocols for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). We developed a peri-operative THA and TKA short stay protocol following the Enhance Recovery After Surgery principles (ERAS), aiming at both optimizing patients’ outcomes and reducing the hospital length of stay. The objective of this study was to evaluate the implementation of our ERAS short-stay protocol. We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital length of stay and reduced direct health care costs compared to our standard procedure. METHODS. We compared the complications rated according to Clavien-Dindo scale, hospital length of stay and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. RESULTS. Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). Postoperative complications that were experienced by significantly more patients in the control group included pain (67% vs 13%, p<0.001), nausea (42% vs 12%, p<0.001), vomiting (25% vs 0.9%, p<0.001), dizziness (15% vs 4%, p=0.006), headache (4% vs 0%, p=0.04), constipation (8% vs 0%, p=0.002), hypotension (26% vs 11%, p=0.003), anemia (8% vs 0%, p=0.002), oedema of the operated leg (9% vs 1%, p=0.005), persistent lameness (4% vs 0%, p=0.04), urinary retention (13% vs 4%, p=0.006) and anemia requiring blood or iron transfusion (8% vs 0%, p=0.002). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital length of stay for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p bellow 0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489% per THA and 4206% per TKA. DISCUSSION AND CONCLUSION. Shorter hospitalization time after THA and TKA is associated with lower risk of nosocomial infections and adverse events related to reduced mobilization such as venous thromboembolism, pulmonary atelectasis, and constipation. In addition, it increases bed availability in a restricted environment and is very favorable economically for the care provider. Multiple strategies have been described to reduce hospital length of stay. One attractive option is to follow the ERAS principles to improve patient experience to a level where they will feel confident to leave for home earlier. Implementation of a ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital length of stay, but also in improved patient care and reduced direct health care costs

Background. The second generation metal-on-metal (MoM) prosthesis of the hip became a worldwide success in the 90s. However, after the placement of a MoM prosthesis the cobalt ion concentrations raise significantly. This may lead to systemic complaints and even cobalt toxicity. Methods. Sixty-one patients (26F/35M) with both an unilateral and bilateral resurfacing or large-head MoM (LHMoM) hip prosthesis were included. At last follow-up (5.77 ± 1.57 yrs) cobalt concentrations in the blood were determined by ICP-MS. Based on the known cobalt toxicity symptoms we developed a non-validated questionnaire. Analysis was done on two groups; a low cobalt concentration group and a high cobalt concentration group. We used 170 nmol/L as the upper limit of well functioning prosthesis as defined by the Dutch Orthopaedic Society (NOV). Independent samples T test and Pearson correlation coefficient were done. Results. In 61 patients, 70 prosthesis were implanted: 44 resurfacings and 26 LHMoM. Mean cobalt and chromium ion concentrations were 110 ± 138 (9 – 833) and 104 ± 138 (6 – 592) nmol/L. The low cobalt concentration group consisted of 52 patients, while the high cobalt concentration group consisted of 9 hips. With respect to the systemic complaints, the subjects in the high or low group reported no significant differences. A trend towards more complaints with visual problems (75% vs 51.9%, P = .089) and dizziness (62.5% vs 38.9%, P = .098) was notable in the high cobalt concentration group. Conclusions. Metal on metal hip arthroplasty stays controversial for the possible side-effects. This study shows trends, but no significance, in systemic complaints from high cobalt ion concentrations. Complaints of neuro-ocular toxicity are most common. This is in correspondence with other literature, although the upper limit for cobalt ion concentrations remains uncertain. Level of Evidence. 2b. Disclosure. no financial or nonfinancial relationships to disclose

Aims

The primary aim of this study was to assess the feasibility of recruiting and retaining patients to a patient-blinded randomized controlled trial comparing corticosteroid injection (CSI) to autologous protein solution (APS) injection for the treatment of subacromial shoulder pain in a community care setting. The study focused on recruitment rates and retention of participants throughout, and collected data on the interventions’ safety and efficacy.

Unicompartmental knee replacements offer improved function with more rapid recovery compared to TKR. There is no published experience with introducing this procedure as a day case in the UK. We report on our experience with a new protocol allowing the patient to be discharged on the day of surgery. A new combination of anaesthetic and surgical techniques are employed. Paracetamol, ibuprofen and pregabalin are given pre-operatively. Patients receive a GA and a subsartorial saphenous nerve block is administered under ultrasound control. The surgery is performed using a routine minimally invasive technique. The joint and surrounding tissues are infiltrated with a combination of LA and adrenaline. Wound closure is with subcutaeneous suture and tissue glue. Patients are mobilised on the day of surgery and if comfortable discharged on paracetamol, codeine, ibuprofen, tramadol P.R.N and buprenorphine patch. Length of stay, pain scores, presence of nausea/vomiting, dizziness, drowsiness, post-operative bleeding and patient satisfaction are all recorded. 18 out of 19 patients have been discharged on the day of surgery. All record high satisfaction. Patients can be safely discharged on the day of surgery after UKR with high levels of satisfaction. We believe we are the first unit in the UK to achieve this

Introduction. The use of narcotic medications to manage postoperative pain after TJA has been associated with impaired mobility, diminished capacity to engage in rehabilitation, and lower patient satisfaction [1]. In addition, side effects including constipation, dizziness, nausea, vomiting and urinary retention can prolong post-operative hospital stays. Intraarticular administration of local anesthetics such as bupivacaine – part of a multimodal postoperative pain management regimen – reduces pain and lowers patients' length of stay [2]. In addition to its anesthetic activity, bupivacaine also has antibacterial activity, particularly against gram-positive bacteria [3]. We have developed a bupivacaine-eluting ultrahigh molecular weight polyethylene (Bupi-PE) formulation; we hypothesized that elution of bupivacaine from polyethylene could have both anesthetic and antibacterial effects in vivo. Methods. In Vivo Antibacterial Efficacy. A total of n=10 male Sprague Dawley rats (250 g) were used in this study. Polyethylene (control) or Bupi-PE plugs (2.5 mm diameter × 5 mm length) were implanted subcutaneously in the rat dorsum. After incision site closure, 5 × 10. 7. cfu of bioluminescent S. aureus were injected around the implants. Bioluminescent signal (photos/second) was measured daily. All rats were euthanized after one week. In Vivo Anesthetic Efficacy. A total of n=10 male Sprague Dawley rats (250 g) were used in this study. Polyethylene (control) and Bupi-PE plugs (2.5 mm diameter × 5 mm length) were implanted into rat knees via a lateral transcondylar approach (Figure 1a). Efficacy was determined by performing a walking track analysis using a highly sensitive Tekscan. ®. sensor (VHR, 5101) (Figure 1b). Walking tracks were performed at baseline (pre-surgery) and every 24 hours for two weeks. All rats were euthanized after two weeks. Results. In Vivo Antibacterial Efficacy. One control rat expired at day 3 and another one expired in day 7. None of the Bupi-PE rats expired during the study. Significantly less bacterial load was observed in rats receiving Bupi-PE, starting at 24 hr post implantation, continuing until the end of study (day 7) (Figure 2). In Vivo Anesthetic Efficacy. 24 hr post surgery, rats in the control group loaded their unoperated hindlimb significantly more than their operated hindlimb. Rats with the Bupi-PE implant loaded both their hindlimbs similarly (Figure 1c). Discussion. The antibiotic activity of the Bupi-PE against an acute S. aureus infection in the subcutaneous dorsum determined that bupivacaine elution from UHMWPE effectively eradicated bacteria within the implant perimeter. In the joint, the release of bupivacaine allowed prompt weightbearing and joint mobilization compared to controls. Conclusion. Bupivacaine-eluting UHMWPE effectively reduced bacterial load in murine subcutaneous dorsum and reduced postsurgical pain in a murine intra-articular model. This material can be promising for use as infection prophylaxis and pain management after TJA. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Aims

Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone.

Purpose: Whiplash injury occurs due to motor vehicle accidents has its long term consequence, nevertheless very little is written about its long-term follow up. The aim of the study is to find out the long-term follow up of Whiplash injury and the factors affecting the long-term follow up. Method: It is a retrospective study which was done in Russells Hall Hospital in the west midland in UK. 64 patients were selected in this study. Only 54 patients were replied. An inclusion criterion was Whiplash injury due to RTA in years 1995, 1996 and 1997. Initial examination was performed 5.6 +/ – 4.5 days after trauma, and follow-up examinations 3, 6, 12, and 24 months. Exclusion criteria were any cervical spine bony injury, associate head injury and poly-trauma patients. The outcome measures used for assessment are SF36, Whiplash Disability Questionnaire score WDQS, and questions to cover their present symptoms, work circumstances before and after the injury, current and previous treatment. Results: In our study we found that the time it takes for the patient’s symptoms to resolve varies, it took less than 6 weeks in 4 patients, between 6 weeks to 3 months in 10 patients, between 6 months to 1 year in 15 patients and more than one year in 3 patients. The average follow up time was 10.3 years. Our results did show these figures: 22 patients were still symptomatic 10 years after injury, 18 still complaining of pins & needles, 13 still having frontal headache and 7 having occipital headache. Headache was one of the symptoms which annoyed Whiplash injury patients. Headaches following Whiplash injuries were occipital, frontal or generalised. Headache was usually of Muscular contraction type, often associated with greater occipital neuralgia. 16 patients still had treatment in the form of pain killers or physiotherapy. The mean WDQS was less than 20 in 38 patients. The mean WDQS in patients with low back pain was 29.23 and for those without back pain were 12.53. In the smokers the mean whiplash score was 32.2. In the non-smokers the Whiplash score was 17.93. The mean WDQS in those who do not drink alcohol was 26.73 and in those who drink alcohol were 16.58. Conclusion: Whiplash injury patients have long term residual symptoms mainly pins & needles as well as headache and dizziness. Claiming compensation is a bad prognostic factor on the long-term outcome of Whiplash injury patients. Drinking alcohol, Gender, BMI, treatment given after the initial injury and smoking have no effect on the long-term outcome of these injuries. Age & Low back pains are bad prognostic factors. Whiplash Disability Questionnaire score, SF 36 (for body pain) and time for symptoms to be relieved are sensitive outcome measures to assess those injuries

Introduction: Long-term treatment of chronic muscu-loskeletal pain with opioids often causes a cluster of unpleasant side effects such as constipation, dizziness and cognitive impairment and is likely to lead to tolerance and to hyperalgesia, which is clinically important but not yet well researched. In this study we investigated the development of hyperalgesia after long-term treatment with opioids in patients with chronic low back pain (cLBP). The goal of this prospective longitudinal study was to investigate the long-term (> 1.5 years) effects of opioid analgetics on thermal sensation and pain thresholds and to follow the changes in pain sensitivity for 6 months during opioid withdrawal. Methods: Using quantitative sensory testing (QST), we compared thermal sensation and pain thresholds on the palm of the hand and the low back bilaterally among three groups: patients with cLBP and long-term treatment with opioids (group 1, n=35); opioid-naive patients with chronic low back pain (group 2, n=34) and subjects with neither pain nor opioid intake (group 3, n=27). The effects of age, sex, pain duration, duration and dose of opioid intake, comorbidity (depression) and self-reported pain intensity assessed by QST were investigated. All patients were allocated to a 3-week multidisciplinary functional restoration programme that emphasized biopsychosocial factors and included continuous tapering of opioid dose. During the study all patients kept records of the medication they used. Results: Group 1 patients showed significantly delayed reaction to cold and warm stimuli on the back, compared with both group 2 and group 3. Pain thresholds for cold and heat on the hand were similar in group 1 and 2 but significantly reduced in these groups compared with group 3. Age, sex, pain duration, duration and dose of opioid intake, and self-reported pain intensity, but not depression, correlated significantly with QST results. Discussion: The present study demonstrated that long-term opioid use significantly delayed thermal QST responses but had no measureable analgesic effects in patients with chronic low back pain. While the pain thresholds in groups 1 and 2 did not differ before opioid withdrawal, both groups 1 and 2 were more sensitive to pain than group 3 (healthy controls). This finding confirms that chronic low back pain itself might cause increased pain sensitivity, which seems not to be counteracted by opioid medication. Rather, treatment in the multidisciplinary pain therapy programme had positive effects on pain thresholds in opioid-naive patients but not in patients after opioid withdrawal. The opioid-naive patients of group 2 showed normalized pain thresholds 6 months after therapy, while the former opioid-positive patients of group 1 still had significantly decreased pain thresholds despite 6 months’ abstinence

Introduction and Aims: Caudal and lumbar epidural steroid injections have had a contentious history in the treatment of lumbar radiculopathy. We set out to assess the efficacy of these injections with relation to key discriminators and to assess the safety of these injections. Method: After a literature search highlighted several possible discriminators regarding outcomes for lumbar radiculopathy and surgery we undertook a pilot study to assess the above aims. This took the form of a retrospective telephone interview. When our pilot study reached statistical significance after only 25 patients, we undertook a retrospective study of all 138 patients who had received a caudal or epidural steroid injection for radiculopathy in the last eight years. This took the form of a postal questionnaire, with telephone interview follow-up. Appropriate statistical analysis was performed for the paired and non-paired data collected. Results: Of the 138 patients, 105 could be traced and of these it was possible to compare caudal vs. lumbar epidural in 75. All other comparisons were made on the full available population (105). We showed a statistically significant difference in the following: (i) an overall reduction in pain scores from 7.78 to 5.16 (mean values, difference –2.62, p< 0.0001); (ii) an overall increase in march tolerance from 804m to 1788m (mean values, difference 984m, p,0.0001); (iii) smokers had a higher level of pain overall before, immediately after and longer term than non(N)smokers (mean values smokers vs. non are; before 8.25:7.4, immediately 5.75:4.269, long-term 6.708:5.173, p< 0.01). We found no significant difference between sexes, activity-provoked pain, cough/impulse pain, unemployment due to pain or number of injections received. We had only one serious complication (anaphylactoid reaction) and 10 minor complications including headaches (five), pain at injection site (two), dizziness (one), hot flushes (one) and one diabetic patient had different insulin requirements for two days. Conclusion: Although more research, ideally in the form of a randomised, controlled, double-blind trial is indicated, we have concluded that by either route these injections are a safe and effective measure of temporary pain relief for lumbar radiculopathy and that smoking is associated with higher levels of pain