In a prospective multicentre study we investigated variations in pain management used by knee arthroplasty surgeons in order to compare the differences in pain levels among patients undergoing total knee replacements (TKR), and to compare the effectiveness of pain management protocols. The protocols, peri-operative levels of pain and patient satisfaction were investigated in 424 patients who underwent TKR in 14 hospitals. The protocols were highly variable and peri-operative pain levels varied substantially, particularly during the first two post-operative days. Differences in levels of pain were greatest during the night after TKR, when visual analogue scores ranged from 16.9 to 94.3 points. Of the methods of managing pain, the combined use of peri-articular infiltration and nerve blocks provided better pain relief than other methods during the first two post-operative days. Patients managed with peri-articular injection plus nerve block, and epidural analgesia were more likely to have higher satisfaction at two weeks after TKR. This study highlights the need to establish a consistent pain management strategy after TKR

Aims. The aim of this study was to determine the optimal regimen for the management of pain following total knee arthroplasty (TKA) by comparing the outcomes and cost-effectiveness of different protocols implemented at a large, urban, academic medical centre. Patients and Methods. Between September 2013 and September 2015, we used a series of modifications to our standard regimen for the management of pain after TKA. In May 2014, there was a department-wide transition from protocols focused on femoral nerve blocks (FNB) to periarticular injections of liposomal bupivacaine. In February 2015, patient-controlled analgesia (PCA) was removed from the protocol while continuing liposomal bupivacaine injections. Quality measures and hospital costs were compared between the three protocols. Results. The cohort being treated with PCA-less liposomal bupivacaine injections had a significantly higher percentage of patients who were discharged to their home (p = 0.010) and a significantly shorter length of stay (p < 0.001). Patient-reported Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores relating to pain being “well-controlled” and “overall pain management” also favoured this cohort (p = 0.214 and p = 0.463, respectively), in which cost was significantly lower compared with the other two cohorts (p = 0.005). Conclusion. The replacement of FNBs injections and the removal of PCAs, both of which are known to be associated with high rates of adverse outcomes, and the addition of liposomal bupivacaine periarticular injections to a multimodal pain regimen, led to improvements in many quality measures, HCAHPS pain scores, and cost-effectiveness. Cite this article: Bone Joint J 2018;100-B(1 Supple A):55–61

Abstract. Introduction. Adverse reactions to pain medication and pain can delay discharge after outpatient knee arthroplasty (TKA). Pharmacogenomics is an emerging tool that might help reduce adverse events by tailoring medication use based on known genetic variations in the CYP genes determining drug metabolism. This study was undertaken to evaluate whether pre-operative pharmacogenomic testing could optimize peri-operative pain management in patients undergoing total knee arthroplasty (TKA). Methods. This prospective, randomized study was performed in adults undergoing primary TKA. Patients in the experimental group underwent pre-operative pharmacogenomic evaluation and medication adjustments. Medications were not optimized for control patients. The Overall Benefit of Analgesic Score (OBAS) at 24 hours post-op was the primary outcome. Postoperative pain scores (VAS scale), total opioid use, time in recovery, and time to discharge were also compared. Results. 76 patients enrolled. 93% of patients had a poor-intermediate phenotype for at least one of four CYP genes. OBAS did not differ significantly between the two groups (4.2 control vs. 4.7 experimental; 95% CI −1.1 to 2.1) and was below the minimum clinically important difference of 2.0 points. Furthermore, there were no differences in any OBAS subscale including pain, satisfaction, or nausea. There were no differences in time in the recovery area or to discharge from hospital, or narcotic use. Conclusions. Despite many patients having a poor-intermediate phenotype for a CYP gene, pharmacogenomic testing prior to TKA and medication adjustment did not improve anesthesia or pain management outcomes, time to discharge or mean total opioid use after surgery

Great strides have been made in perioperative pain management after total knee arthroplasty (TKA) leading to reduced length of hospital stay, cost reduction, improved patient satisfaction, and more rapid recovery without affecting the rates of readmission after surgery. To assure a happy patient, early recognition of patients at risk for persistent postoperative pain prior to surgery is key. Patients on chronic pain medication should be evaluated by pain management specialists with the intention of reducing overall narcotic requirement prior to TKA. Patients with high anxiety levels, pain catastrophizing, and Kinesphobia are at increased risk for increased pain and poor outcomes and should be referred for cognitive behavioral therapy and coping strategies. Finally, patients with hypersensitivity syndromes localised in the soft tissue around the knee should undergo desensitization protocols prior to TKA. Patient education on the risk of increased postoperative pain is crucial to manage expectations and optimise modifiable risk factors prior to TKA. To assure a happy patient indicated for TKA, a comprehensive pain management strategy divided into pre-, intra-, and post-operative periods should be employed

Pain management following surgery continues to challenge patients, physician-extenders, and surgeons. A recent survey of 300 patients following surgery found that 86% experienced pain following surgery with 75% describing moderate or severe pain. Pain management in 2017 has to better address patient's needs as Pain has become the “5th Vital Sign” and is used in many patient reported outcomes (for better or worse). Multimodal therapy has been defined as “Synchronous administration of ≥ 2 pharmacological agents or approaches, each with a distinct mechanism of action”. Mounting evidence supports the use of a multimodal approach to peri-operative pain management in all surgical subspecialties. A recent systematic review of intravenous ketamine showed a reduction total opioid consumption and an increase in the time to first analgesic dose needed across all studies. Gabapentin and pregabalin have both been shown to dramatically reduce the use of opioid consumption by 30%. We have worked with our anesthesia team and developed a multimodal analgesia program that includes ketorolac 10mg 3 tabs po qd × 3 days, then 10mg 2 tabs po × 2 days; gabapentin 300mg (<65 year old) or 100mg (>65 year old) 3 tabs po × 3 days; oxycodone 5mg po q 4–6 hours prn breakthrough pain and Tylenol 500mg 1–2 tabs po q 6 hours prn

Pain control is critical in the management of TKA patients and is crucial to allow for early ambulation and accelerated physical therapy. Currently data suggests that 19% of patients are not satisfied with their results following TKA, and failure to control pain may result in prolonged hospitalization, worse outcomes, and increased patient dissatisfaction. Studies suggest that local analgesics coupled with both pre- and post-operative multimodal pain management may result in improved pain control and increased patient satisfaction. Minimization of opioid use is helpful in decreasing complications, accelerating physical therapy milestones, minimizing length of stay and increasing discharge to home. Femoral nerve blocks (FNB) can reduce pain scores for up to 48 hours post-operatively, but may delay ambulation and result in an increased rate of falls. Periarticular injection (PAI) with local analgesics can provide significant short term relief comparable to FNB and can also facilitate decreased opioid consumption. One commonly used local anesthetic is bupivacaine, but the average half-life of this drug is only 2.7 hours. An alternative to this for PAI during TKA is liposomal bupivacaine (LB). LB is a multivesicular drug designed for rapid absorption, prolonged release of bupivacaine, and analgesia that is maintained for up to 72 hours with a single injection. LB exhibits a bimodal peak of distribution, one immediate associated with extra-liposomal bupivacaine, and a second 10–36 hours later associated with the release of liposomal encapsulated bupivacaine. The safety profile of LB has been investigated and adverse events are similar to standard bupivacaine and demonstrate acceptable tolerability. Multiple studies have demonstrated efficacy of this drug compared to other pain control modalities. LB is highly technique dependent and only one piece of a multimodal pain management protocol. Our study consisted of 1808 consecutive primary TKA patients from Sept 2013 to Sept 2015. Three patient cohorts were compiled by date, from Sept 2013 to May 2014 was cohort 1, consisting of FNB and PCA. Department wide adoption of LB began in May 2014 and became routinely used in all patients undergoing total joint arthroplasty at our institution. Cohort 2 entailed a PCA along with LB injection from May 2014 through Feb 2015. Cohort 3 consisted of LB injection only and was from Feb 2015 through Sept 2015. All patients undergoing TKA were eligible and there were no exclusion criteria as long as the protocols were followed. The standard multi-modal analgesia protocol was provided to all patients in all three cohorts. Prior to entering the operating room, patients received preemptive oral analgesics, consisting of: 200 mg celecoxib, 1000 mg acetaminophen, and 50 mg pregabalin. Intra-operative analgesia was chosen at the discretion of the anesthesiologist and preferentially consisted of spinal anesthesia with general anesthesia as an alternate. For all three cohorts, a peri-incisional analgesic cocktail was injected prior to closure consisting of: 40 cc 0.25% Marcaine, 5 cc of (1 mg/cc) morphine, and 1 cc of (30 mg/cc) ketorolac. Cohorts 1 and 2 received PCA post-operatively for pain control post-operatively with prn oral narcotic administration as well. Cohort 3 did not receive a PCA. The cohort treated without FNB and without a PCA using a multimodal pain management protocol including a short acting periarticular injection and a longer acting periarticular injection with LB, had equivalent pain control, less narcotic use, faster achievement of physical therapy milestones, earlier and more frequent discharge home, less complications and a lower cost of the episode of care

Abstract. Background. ‘Free From Pain’ is a drug-free, injection injection-free, lifestyle-based musculoskeletal pain management programme for seniors. The programme empowers Seniors with relevant information and inspirational metaphors whilst providing them with validated exercises. The programme is also available as a published book (ISBN-0995676941). This pilot study aimed to assess the suitability and safety of the programme's exercises and the usefulness of the book before considering a larger study. Methods. Participants used 5-point Likert scales to evaluate the exercises. A rating of three or below on a Likert scale denoted non-agreement to a positive statement regarding the exercises. A rating of four or above denoted agreement. The Usefulness Scale for Patient Information Material (USE) was utilised to assess the book. Results. Of 30 participants who attended the programme, 25 completed the questionnaire (19 females and six males), with a mean age of 76 years. All the 25 participants were in agreement that the exercises were suitable, (x? = 4.6) and safe (x? = 4.56). 23 participants would also recommend the programme to family and friends? (x? = 4.48). The USE scale is divided into three, sub-domains: cognition (knowledge obtained); emotional (individual's ability to cope with the illness); and behavioural (ability to self-manage). The mean scores for the book on the cognitive, emotional, and behavioural sub-domains were 25.48, 24.08 and 24.04, respectively. Conclusion. Results indicate that the ‘Free From Pain’ exercises are suitable and safe. The book provides educational information that empowers participants to better their musculoskeletal health

The entirety of the patient experience after contemporary total knee and total hip replacements in 2016 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilisation therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to pro-actively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some included gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

To determine the effect of Dexamethasone on post-operative pain management in patients undergoing Total Knee Arthroplasty in terms of numerical pain rating scale and total opoid consumption. This Randomized Controlled Trail (RCT) was conducted for 02 years (7th September 2015 to 6th September 2017). All patients undergoing primary Unilateral Total Knee Replacement (TKR) for Osteoarthritis knee were included in the study. Patients with poor glycemic control (HbA1c > 7.6), Hepatic/Renal failure, corticosteroids/ Immunosuppression drug usage in the last 06 months, known psychiatric illnesses were excluded from the study. All patients were operated by consultant Orthopaedic surgeon under Spinal Anaesthesia and tourniquet control using medial para-patellar approach. Patients were randomly divided into 02 groups, A and B. 79 patients were placed in each group. Group A given 0.1mg/kg body weight Dexamethasone Intravenously 15 minutes prior to surgery and another dose 24 hours post-operatively while in group B (control group) no Dexamethasone given. Post-operative pain using the numerical pain rating scale (NRS) and total narcotics consumed converted to morphine dose equivalent noted immediately post-op, 12-, 24- and 48-hours post-operatively. Data analysis done using SPSS version 23. A total of 158 patients were included in the study. Of the total, 98 (62.02%) were females and 60 (37.98%) males. Average BMI of patients 26.94 ±3.14 kg/m2. Patients in group A required less post-operative analgesics (p < 0 .01) and had a better numerical pain rating scale score (p < 0 .01) as compared to group B. Pain scores at 24- and 48-hours post-op were significantly less for Dexamethasone group (p < 0 .01). Use of Dexamethasone per- and post-operatively reduces the pain and amount of analgesics used in patients undergoing TKA. For any reader queries, please contact . drjunaidrmc@gmail.com

The entirety of the patient experience after contemporary total knee and total hip replacements in 2016 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilization therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to proactively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anaesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some included gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

Perioperative pain involves both neurogenic and inflammatory mediators. The neurogenic component is produced by the intense stimulation of the surgical procedure itself. However, inflammatory mediators resulting from tissue damage and the release of certain cytokines provoke the inflammatory response. Both the neurogenic and inflammatory elements create central nervous system (CNS) excitability. While conventional pain management responds to pain as it occurs, rather than anticipating it, a more appropriate protocol may involve pre-emptive administration of analgesic medication. By beginning this administration prior to surgery and continuing it throughout the rehabilitation process, CNS pharmacological agents are utilised to achieve the following goals: 1.) decrease the neurogenic component at the wound site; 2.) depress afferent pathways; and 3.) decrease central sensitisation in the spinal column. Our experience with such pre-emptive analgesic clinical trials have included implementation of three different protocols in three groups of patients, Groups A-C. In Group A, a continuous epidural for 72-hours was utilised. A short-term epidural for 2–3 hours, followed by the use of scheduled opioid drugs and the use of anti-inflammatory medications, was used in Group B. Finally, Group C included spinal analgesia with shortacting morphine and the continued use of patient-controlled analgesia (PCA) pumps. In all groups, patients were monitored for the return of motor function, respiratory depression, ileus, pain relief, efficacy in analgesia maintenance, and cost. The following trends were observed among the variances: 1.) approximately equal length of stay in all three groups; 2.) decreased motor function in the continuous epidural group (Group A); 3.) increased ileus in the spinal group (Group C); 4.) equal pain relief in all three groups; 5.) high maintenance in the continuous epidural group (Group A); and 6.) decreased cost when continuous epidurals (Group B) were utilised. In conclusion, of the three methodologies implemented, the continuous epidural had a high failure rate (26%). While spinal analgesia is technically easier and less expensive to perform, it has a poorly defined dose response curve and is associated with an increased incidence of ileus. The scheduled opioid medications proved effective. Pre-emptive analgesia not only significantly suppresses pain, it also provides protective sensation. Our recommendation for pre-emptive pain management consists of the use of multi-modal analgesics attacking various sites along the pain pathway, including regional blocks, oral and parental opioids, topical anaesthetics, and ice. However, ongoing study is required to further delineate appropriate protocol, thorough assessment of consequences, and complications associated with all methodologies. Future protocols to be evaluated at this practice include the local injection of bupivacaine hydrochloride prior to wound closure, in addition to assessing the postoperative integration of rofecoxib into the pain management regime

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).

Over the past fifteen years, the average length of stay for total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and perioperative protocols. Rapid recovery techniques and perioperative protocols have been refined to allow for same-day discharge with improved outcomes. As mentioned, the single most important outcome from the minimally invasive movement has been the multi-modal approach to pain management of patients undergoing arthroplasty. Along with blood loss management, using tranexamic acid and hypotensive anesthetic techniques, this multi-modal program is the most important variable in reducing or avoiding side-effects. In any arthroplasty procedure, side-effects that need to be addressed include the negative effects of narcotics and blood loss. Anesthetic techniques, utilizing local nerve blocks, such as the adductor canal block and sciatic blocks for knee arthroplasty augment intraoperative anesthesia and provide postoperative pain relief and quicker mobilization. Additionally, pericapsular injection with a cocktail of local anesthetic helps significantly with pain relief and recovery reducing the amount of oral narcotic utilised in the early postoperative period. Many have utilised liposomal bupivacaine in these cocktails to successfully increase the period of pain relief. The use of multi-modal perioperative protocols can help avoid narcotics and helps avoid the side-effects of nausea. We also utilise an aggressive prophylactic antiemetic program with dexamethasone, ondansetron and a scopolamine patch. Patients without any significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately two weeks postoperatively. Immediately postoperative, acetaminophen and additional dexamethasone are administered intravenously. The multi-modal protocols to address fear, risk, and side-effects will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. By focusing on the patient and avoiding over-treatment, outpatient arthroplasty is quickly becoming the standard of care for total hip replacement in the same way other procedures transitioned from hospital in-patient surgeries to ambulatory procedures

Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. The hallmark of this program is preemptive pain control with oral anti-inflammatory agents, gabapentin, IV acetaminophen, regional anesthetic blocks that preserve quadriceps function for TKA (adductor canal block) and pericapsular local anesthetics. Over the past two years utilising this type of program over 50% of our joint replacement patients are now returning home the day of surgery

Background. Acute pain following total knee replacements (TKRs) is associated with higher peri-operative opiate requirements and their side effects, longer hospital stay and lower patient satisfaction (Petersen 2014). It may also be associated with higher rates of chronic pain at 1 and 5 years (Beswick 2012). We present a novel technique using combination of Local Infiltration Anaesthesia (LIA) with PainKwell infusion system (Bupivacaine 0.5 @ 4mls and 6mls/hr) to improve pain management following TKRs. Methods. Between October 2015 and March 2016. 110 patients undergoing primary TKR were prospectively studied. All patients studied had spinal anaesthesia (SA) with diamorphine. Demographics between the two groups were similar. Group 1. SA plus LIA plus traditional multimodal analgesia. 32 patients. Group 2. SA plus LIA plus PainKwell for 48 hours rate 4mls. 38 patients. Group 3. SA plus LIA plus PainKwell for 48 hours rate 6mls. 40 patients. Results. Visual analogue pain scores demonstrated a significant difference at 8hrs, 12hrs, 24hrs and 48hrs between group 1 and 3; p<0.05. There was also a statistical difference in opiate usage at 24 hours between the three groups with group 3 using significantly less opiates compared to group 1. There was least consumption of opiates in group 3 patients across all study periods. Conclusions. This study reported that SA plus LIA and PainKwell system was effective in reducing pain following TKRs. It also demonstrated that the technique of SA plus LIA plus PainKwell for 48 hours at a rate 6mls/hr reduced opiate usage by 50% and pain by 30% for these patients. Implications. This technique may help improve rehabilitation and shorten hospital stay following total knee arthroplasties

Purpose. To evaluate the effectiveness of post-operative pain management using the intra-operative peri-articular injection(PAI) and/or electromyography (EMG)-guided preoperative femoral nerve block (FNB) in total knee arthroplasty(TKA). Materials and Methods. From March 2013 to February 2014, 90 knees which underwent primary TKA by one surgeon were included in our study. The patients were classified into three groups; a single injection FNB with an EMG guide (Group I, 30 knees), intra-operative PAI (Group II, 30 knees) and both FNB and PAI (Group III, 30 knees). Pain at rest and moving was evaluated by Visual Analogue Scale (VAS) at postoperative 0, 4, 8, 24 and 48 hours. Postoperative range of motion, time to walking, total blood loss, amount of opioid consumption and complications were compared in each group. Results. VAS immediately after surgery was 67.9 in group I, 54.6 in group II and 54.7 in group III. VAS was significantly higher in group I than group II and III (p=0.005), but was not significantly different between group II and III (p>0.05). VAS at postoperative 4 and 8hr showed similar results. VAS at postoperative 24 hr was 49.6 in group I, 56.4 in group II and 46.7 in group III, which was significantly higher in group II than group I and III (p=0.043). After postoperative 48hr, there were no differences in group I, II and III. The total amount of opioid consumption in group III was smaller than that in group I and II (p=0.017). There were no differences in postoperative range of motion, time to walking and total blood loss. There was one case with temporary peroneal nerve palsy in group II and no infection in all cases. Conclusion. PAI was more effective than FNB for early (0∼8hr) postoperative period after TKA. However, PAI showed rebound pain at 24hr after TKA. PAI in combination with FNB could enhance the effect of postoperative pain management from immediate postoperative period to 24hr

Background. Chronic pain is a complex condition that demonstrates better outcomes in multidisciplinary rehabilitation, typically delivered to groups of patients by tertiary healthcare teams. An inter-disciplinary pain management course for individual patients was developed to increase the scope of physical therapists working in primary care by integrating osteopathic manual therapy with psychological interventions from Acceptance and Commitment Therapy (ACT), a form of ‘3rd wave’ Cognitive Behaviour Therapy. Method and Results. A single cohort study with pre-course (n=180) and post-course (n=79) self-report measures (44% response rate) evaluated six week interventions which combined individual manual therapy with self-management, delivered by teams of qualified and student osteopaths. Data included: quality of life (European Quality of Life Questionnaire); pain, mood and coping (Bournemouth Questionnaire); psychological flexibility (Revised Acceptance and Action Questionnaire); and mindfulness (Freiburg Mindfulness Inventory). Participants were predominantly female (68%), unemployed (59%), with an average age of 49 and pain duration of more than 12 months (86%). Commonly reported symptoms were low back pain (82%), neck pain (60%) and multiple sites (86%). At six months, there were statistically significant improvements in all four outcome measures (p<0.0005), with promising effect sizes in quality of life and pain coping (r=0.52) which appeared to be mediated by changes in psychological flexibility. Conclusions. This innovative, integrated, patient-centred chronic pain management course demonstrated promising outcomes when delivered by osteopaths with varying experience. Randomised clinical trials are now needed to assess outcomes in comparison with standard care, and optimal ways of training physical therapists to deliver effective psychological interventions. Conflicts of interest: No conflicts of interest. Sources of funding: A Department of Health ‘Innovation, Excellence and Strategic Development’ (IESD) grant for the Voluntary Sector Investment Programme (AIMS Ref: 2527190; ISRCTN: 04892266). The results of this study are being submitted for publication in the International Journal of Osteopathic Medicine and will be presented at the COME Collaboration Osteopathic Conference in Barcelona on September 30th 2017 and at the Therapy Expo 2017 at the NEC in Birmingham on November 22nd 2017

Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is pre-emptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and pericapsular long acting time release local anesthetics with the addition of injectable ketorolac and IV acetaminophen. Over the past two years utilising this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. We currently utilise a long acting local anesthetic delivery medication consisting of microscopic, spherical, lipid-based particles composed of a honeycomb-like structure of numerous nonconcentric internal aqueous chambers containing encapsulated bupivacaine separated from adjacent chambers by lipid membranes. Bupivacaine is released from the particles with diffusion of the drug over an extended period of time that more closely matches the time course of postsurgical pain following joint replacement surgery. Trials have demonstrated that a single dose administered via deep tissue infiltration is effective at reducing pain up to 72 hours. This has been trialed in TKA as well

Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay and opened the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is preemptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and long acting local anesthetics with the addition of injectable ketorolac and acetaminophen. Over the past two years utilising this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. We currently utilise a long acting local anesthetic delivery medication consisting of microscopic, spherical, lipid-based particles composed of a honeycomb-like structure of numerous nonconcentric internal aqueous chambers containing encapsulated bupivacaine separated from adjacent chambers by lipid membranes. Bupivacaine is released from the particles with diffusion of the drug over an extended period of time that more closely matches the time course of postsurgical pain following joint replacement surgery. Trials have demonstrated that a single dose administered via deep tissue infiltration is effective at reducing pain up to 72 hours

Background and purpose. The Fear Avoidance Model is used to explain why some patients with acute low back pain develop chronic low back pain (CLBP). Cognitive behavioural therapy (CBT) targeting dysfunctional behavioural cognitions (pain catastrophizing and fear of movement) is recommended. Purpose: to investigate whether a two-week CBT-based pain management program results in improvement in dysfunctional behavioural cognitions and whether these improved cognitions improve functional outcomes. Methods and Results. Cohort study including 524 consecutive CLBP-patients. Main outcome: functioning (ODI). Secondary outcomes: pain severity (NRS), pain catastrophizing (PCS), fear of movement (TSK). Assessments: pre- and post-treatment, 1 and 12-months follow-up (FU). Improvement over time was analysed with repeated measures ANOVA. Path analyses were used to examine the influence of pain catastrophizing and fear of movement on functional disability and pain severity. Multiple imputation was used to complete missing data. Participants with incomplete data (12.8%) did not differ from those with complete data (n= 457). 59% were females, mean age 46 (± 9.5) years, mean CLBP-duration 12 (± 10.8) years. All outcomes significantly improved at post-treatment and a slight significant improvement between post-treatment and 12 months FU was observed. Path analyses showed a direct effect for catastrophizing on post-treatment functioning and an indirect effect for catastrophizing through fear of movement on post-treatment functioning. Comparable results with pain severity as outcome. Conclusion. A two-week pain management program improved dysfunctional behavioral cognitions and functional outcomes in patients with longstanding CLBP up to one year. Targeting both pain catastrophizing and fear of movement during the program resulted in improved outcomes. Conflicts of Interest: JK O'Dowd is director of and shareholder in RealHealth. The authors declare that this abstract has not been previously published in whole or substantial part nor has it been presented previously at a national or international meeting. Sources of Funding:. No funding obtained

The April 2024 Children’s orthopaedics Roundup. 360. looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study

Total Knee Arthroplasty (TKA) improves the quality of life of osteoarthritic and rheumatoid arthritis patients, however, is associated with moderate to severe postoperative pain. There are multiple methods of managing postoperative pain that include epidural anesthesia but it prevents early mobilization and results in postoperative hypotension and spinal infection. Controlling local pain pathways through intra-articular administration of analgesics is a novel method and is inexpensive and simple. Hence, we assess the effects of postoperative epidural bupivacaine injection along with intra-articular injection in total knee replacement patients. The methodology included 100 patients undergoing TKA randomly divided into two groups, one administered with only epidural bupivacaine injection and the other with intra-articular cocktail injection. The results were measured based on a 10-point pain assessment scale, knee's range of motion (ROM), and Lysholm knee score. The VAS score was lower in the intra-articular cocktail group compared to the bupivacaine injection group until the end of 1-week post-administration (p<0.01). Among inter-group comparisons, we observed that the range of motion was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Lysholm's score was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Our study showed that both epidural bupivacaine injection and intra-articular injection were effective in reducing pain after TKA and have a comparable functional outcome at the end of 4 weeks follow up. However, the pain relief was faster in cases with intra-articular injection, providing the opportunity for early rehabilitation. Thus, we recommend the use of intra-articular cocktail injection for postoperative management of pain after total knee arthroplasty, which enables early rehabilitation and faster functional recovery of these patients

Introduction and Objective

Postoperative pain control in shoulder surgery is challenging even in arthroscopic procedures. Acute postoperative pain can last up to 48hrs despite using multimodal analgesia. Different techniques have been used to control acute pain following shoulder surgery. The most common technique currently used in shoulder surgery at the elective orthopaedic centre in Leeds is a combination of general anaesthetic (GA) and interscalene block (ISB). ISB maybe very effective, however, carries many risks and potential side effects such as brachial plexus injury and paralysis of the vagus and laryngeal recurrent nerves as well as cervical sympathetic nerve and pneumothorax. ISB can also be associated with higher incidence of neurological deficit compared to other peripheral nerve blocks; up to 14% at 10 days in some cases. As such we decided to examine the use of ISB for achieving pain control in our elective unit.

Background. Narcotics are commonly prescribed for pain control of orthopedic trauma but injury pattern and severity, in addition to patient factors, result in varying dosing requirements. These factors, coupled with increasing pressure to reduce narcotic consumption, highlight the importance of narcotic stewardship and comprehension of patient factors leading to higher pain control demands. The purpose of this study is to understand whether or not narcotic consumption is greater in patients who present to the emergency department with positive drug screen (utox) for illicit substances. Methods. We performed a retrospective chart review of 300 consecutive trauma activations during the 2015 calendar year. Of the patient cohort, 226 patients received a utox screen which represents the cohort for this study. Utox screen included amphetamines, barbiturates, benzodiazepines, cocaine, ethanol, methadone, phencyclidine, and tetrahydrocannabinol. Opioids given hospital stay were converted to oral morphine equivalents using ratios available in the current literature. The average daily equivalent was calculated for their total hospital stay and recorded. Patient injury severity score (ISS), age, gender, length of stay, readmission rates were also recorded. Statistical comparisons were made using SPSS version 23 (IBM, Aramonk, NY). Data distributions were examined with the Shapiro-Wilk test of normality between group comparisons were made with Mann Whitney U tests. Chi squared test was used to evaluate categorical data. Significance was set at p=0.05. Results. There were 108 (48%) positive utox tests of the 226 that received a utox test. There was no difference in gender distribution or age between the 2 groups. The calculated morphine equivalent consumption of the positive utox patient cohort was compared against the negative utox group. The median daily oral morphine equivalents in the positive utox group was 23.85 versus 12.05 for those with a negative utox screen. This was found to be statistically significant with a p value of 0.014. The average length of stay for the positive utox group was 3 days versus 2 days for the negative utox group. This also was statistically significant with a p value of 0.009. There was no statistical significance for ISS (5 in utox positive versus 5 in utox negative patients) nor was there any significance found in the rate of readmissions. Discussion. Our study shows that infividuals found to have positive utox screening for illicit drug use require more opioids for pain control and have longer hospital stays. These increased resource requirements exist despite no statistically significant difference in ISS. The high rate of positive findings and differences in patient clinical course support continued utox screening in trauma activation patients. When treating these patients, physicians should be aware of potential differences in pain management strategies and would likely benefit from multimodal pain control progam

Total Knee Arthroplasty (TKA) is a successful treatment for end stage osteoarthritis of the knee joint. However, post-operative pain can lead to patient dissatisfaction and poorer outcomes. Cooled radiofrequency nerve ablation (CRNA) has reportedly been effective at treating pain osteoarthritic knee pain by targeting the periarticular nerves of the knee. We undertook a prospective, controlled pilot study to determine if CRNA provides effective post-operative analgesia when utilised intra-operatively during total knee arthroplasty.

Participants were recruited from January 2019 to February 2020. Those meeting inclusion criteria underwent TKA with intraoperative CRNA to 6 target sites prior to the cementing of implants. The primary outcomes were pain scores and opiate usage in the first 4 days post-operatively, then weekly up to 6 weeks. A total of 62 patients were screened and allocated sequentially; 18 were recruited to the control group and 12 recruited to the study group. The two groups did not have any significant difference in demographics.

There were no clinically significant differences between the two groups in terms of pain scores nor opiate usage. There were complications as a result of the intervention.

This study demonstrated no benefit of using intraoperative CRNA for improving post-operative pain scores or reducing opiate use after TKA.

Refinement of surgical techniques, anaesthesia protocols, and patient selection have facilitated this transformation to same day discharge for arthroplasty care, most notably Partial Knee Arthroplasty (PKR). The trend for early discharge has already happened for procedures formerly regarded as “inpatient” procedures such as upper extremity surgery, arthroscopy, ACL reconstruction, foot and ankle procedures, and rotator cuff repair. Our program began focused on Partial Knee Arthroplasty (PKA) and has now expanded to primary TKA and THA, and select revision cases. Over the past few years we have performed 1,230 Knee Arthroplasty procedures with no readmissions for pain control. Average age and age range is identical to our inpatient cohort for our partial knee cases. Patient selection is based on medical screening criteria and insurance access. PKA is the ideal procedure to begin your transition to the outpatient space. We currently perform medial PKA, lateral PKA, and patellofemoral arthroplasty as outpatient cases. The program centers on the patient, their family, home recovery, pre-operative education, efficient surgery, and represents a shift in the paradigm of arthroplasty care. It can be highly beneficial to patients, surgeons, anaesthesia, facility costs, and payors as arthroplasty procedures shift to the outpatient space. Perhaps the most significant developments in joint replacement surgery in the past decade have been in the area of multimodal pain management. This has reduced length of stay in the inpatient hospital environment opening the opportunity for cost savings and even outpatient joint replacement surgery for appropriately selected patients. The hallmark of this program is meticulous protocol execution. Pre-emptive pain control with oral anti-inflammatory agents, gabapentin, regional anesthetic blocks that preserve quad function for TKA (adductor canal block) and pericapsular long acting local anesthetics with the addition of injectable ketorolac and IV acetaminophen are key adjuncts. Over the past two years utilizing this type of program over 60% of our partial knee replacement patients are now returning home the day of surgery. Concerns over readmission are appropriate. The rates of complications and readmissions are less than our inpatient cohort in appropriately selected cases with a standardised care map. We believe this brings the best VALUE to the patients, surgeons, and the arthroplasty system

Pain management has remained a challenge for surgeons since the dawn of organised medicine. A massive influx of unproven techniques and alternative therapies has descended upon us with little regard to true efficacy and even safety. It is incumbent upon us as practitioners of medicine to finally begin to pay more attention to the tenets of evidenced based medicine while making therapeutic choices. Johns Hopkins has had a long history of dealing with pain in many of its chameleon forms ranging from the management of acute post-operative pain to the more difficult management of chronic pain. To effectively manage pain in a surgical practice requires attention to first establishing the type of pain (ie. nociceptive or neuropathic). Once the type of pain is clear, specific algorithms can be worked out based on the principles of evidenced based medicine which can be carried out by a variety of paramedical personnel (ie. Physician Assistants or Nurses) without specific surgeon input. This maximises benefit to the patient and minimises problems for the surgeon. Specific algorithms for the management of acute LBP, chronic LBP, acute postoperative pain, chronic postoperative pain, cancer pain and sociopathic pain will be discussed

Aims

Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes.

Aims

The purpose of this study was to use pharmacogenetics to determine the frequency of genetic variants in our total knee arthroplasty (TKA) patients that could affect postoperative pain medications. Pharmacogenetic testing evaluates patient DNA to determine if a drug is expected to have a normal clinical effect, heightened effect, or no effect at all on the patient. It also predicts whether patients are likely to experience side effects from medicine. We further sought to determine if changing the multimodal programme based on these results would improve pain control or reduce side effects.

Purpose and background. A review of secondary healthcare provision for civilians suffering persistent pain and living in the British Forces Germany (BFG) community was carried out in order to better inform referral from primary care. This population consists mostly of British nationals each with differing linguistic skills and cultural backgrounds. Patients may be referred to Evangelisches Krankenhaus Bielefeld (EvKB) in Germany or to Guys and St Thomas' NHS Foundation Trust (GSTT) in the UK. It was considered important to identify potential language or cultural-related barriers to improve decision making when considering where best to refer for a pain management programme (PMP). Methods. Clinical visits undertaken at GSTT and EvKB involved observation of clinical activities, collection of documentation and informal staff discussions. Data were organised into common themes and categorised to provide information for written reflective accounts on each visit. Results. The PMP at EvKB is medical doctor-led, supported by integrated psychologists. English language skills of individual staff members appear varied. Patients stay in shared rooms on a medical ward environment. Group based pain education here is provided in German only. Access to the GSTT PMP requires competent English language skills. It is psychologist-led and delivered by an interdisciplinary team. Patients reside in individual living accommodation and attend group therapy sessions. Conclusion. To reduce risk of increasing anxiety, cultural differences related to language, medical hierarchy and privacy should be considered before referring non-German speakers with complex psychosocial needs to EvKB. Given the complexity of pain, non-native speakers may misunderstand translations of cultural nuances used in pain education. No conflicts of interest. Funding was received by the primary author from SSAFA Forces Help for dissertation tuition fees. This work formed part of a project submitted in partial fulfilment of the requirements for the degree of MSc Clinical Management of Pain at the University of Edinburgh

Background and Aim: The aim of this study was to measure the change in disability following a 2-week cognitive behavioural pain management program. Methods: Subjects (n=67) were patients with chronic low-back pain referred to the 2-week, 70 hour program, who had no further medical treatment available. At referral their disability was assessed by way of the Oswestry Disability Index (ODI) and the Roland Morris Disability Questionnaire (RMDQ). The program is aimed at changing their behaviour, and returning them to normal function as much as possible. Data were assessed at intake, at the end of the 2-week program, and at follow-up after 1 month and after 1 year. Results: Over the 2-week programme period there is a sharp decrease in the ODI and the RMDQ scores. ODI scores went from 38 to 29 (range 0–100), RMDQ scores went from 14 to 8 (range 0–24). Over the 1-year follow-up there is an additional decrease in ODI score of 6 points and an additional decrease in RMDQ score of 1 point. Conclusion: The sharp decrease in disability scores over the 2-week programme period shows that cognitive factors, i.e. the perception of disability by the patients plays an important role, since two weeks is not adequate time to see significant improvement in physical function. The change in behaviour that results from the program may lead to the further reduction in disability scores

It is important to optimise not only the operative treatment, but also the general medical condition of hip fracture patients to achieve the best rehabilitation result. Patients with a hip fracture are old and often suffer from concomitant diseases. They are prone to be affected by complications such as pneumonia, urinary tract infection and pressure ulcers. The total treatment situation with sufficient intake of food and drink, pain management, prevention of pressure ulcers and a rapid handling from arrival at the Acute and Emergency unit until the patient has been operated is crucial. We have studied the nutrition and drink in patients with a hip fracture and in spite of repeated instructions to eat and drink sufficiently the patients with the hospital standard food achieve only 54% of their optimum energy needs and 64% of the fluid necessary. With an extra addition of nourishment to the hospital food the total energy and fluid intake reach almost the calculated level of need for these patients. The amount of complications, particularly infections, were significantly lower in the well nourished group. We have also started to optimise the immediate acute treatment and already in the ambulance the patients now receive pain treatment, intravenous fluid and oxygene administration. The patients receive 3 litres of oxygene/min preoperatively and the first days postoperatively. The waiting time on hard surfaces has diminished through change of mattresses, but also with a much more rapid handling time through the X-ray department and the Emergency department. Routines have changed so the patients will not have to return to the Acute and Emergency after X-ray. Instead they are transported directly to the orthopaedic ward. Furthermore, the patients are given a higher priority in the waiting list among the acute surgery cases. All patients are evaluated for the risk of development of pressure ulcers and those at risk get special mattresses. With these measures the development of pressure ulcers during the time in hospitals has diminished by half. Special attention is also given to the patients’ mental status. At admission to hospital one third of the patients are not lucid. All these factors are of major importance for the rapid mobilisation of the patient in the acute ward and the continued rehabilitation

The postoperative pain after hip arthroscopy remains a major challenge in the immediate postoperative period. Adequate postoperative analgesia has been associated with increased patient satisfaction and decreased consumption of opioids. We evaluated the efficacy of pericapsular nerve group block (PENG) versus fascia iliaca block (FIB) in reducing post-operative pain and analgesic consumption within the first 24 hours following arthroscopic management of femoroacetabular impingement (FAI).

Thirty-nine patients (17 females and 25 males, ages 18–42 years, mean ± SD (27.9 ± 6.2), and mean BMI of 25.13±5.08 kg/m2 were scheduled for primary arthroscopic management of FAI. Included patients were randomized into two groups according to the block used in each. Group (A) 19 patients were included and had FIB and group (B) 20 patients were included and received PENG block. The efficacy of both techniques was clinically and statistically valuated using VAS score and quadriceps muscle power.

There was a statically significance difference in the mean at rest between the two groups at all measured time points following surgery (6, 12, 18 and 24 h). Also, in dynamic pain scores (with hip flexion) scores were statistically significant at 24 hours post-operative (P = .001). Total opioid consumption in the first 24 hours postoperative was lower in the PENG group with significant difference of mean 16.5 ±9.9 mg for PENG group versus 27.5±9.6 mg for FIB group (P < .005). Five patients (26.31%) in FIB group had weaker quadriceps muscle power while none in PENG group patients had quadriceps weakness.

PENG block might be considered as an ideal regional anesthesia modality for hip arthroscopy. As an alternative to more conventional regional nerve blocks such as a fascia iliaca block. PENG block is easily performed in the preoperative setting, and appears to spare motor function while providing a prolonged sensory pain relief.

Total hip arthroplasty (THA) is reliable and reproducible in relieving pain and improving function in patients with end-stage arthritis of the hip joint. With improvements in surgical technique and advances in implant and instrument design, there has been a shift in focus from the technical aspects of the surgical procedure to improving the overall patient experience. In addition, shifts in medico-economic trends placed a premium on early patient mobilization, early discharge, and maximizing patient satisfaction. Arguably, a single most important advance in arthroplasty over the past 2 decades has been the development of multimodal pain protocols that form the foundation of many of the rapid recovery protocols today.

The principal concept of multimodal analgesia is pain reduction through the utilization of multiple agents that synergistically act at various nodes of the pain pathway, thus, minimizing patient exposure to each individual agent and opioids in order to prevent opioid related adverse events (ORAE). Regional anesthesia has been shown to reduce post-operative pain, morphine consumption, and nausea and vomiting compared to general anesthesia but not length of stay. Additionally, general anesthesia has been shown to be associated with increased rates of post-operative adverse events, The use of peripheral nerve blocks in the form of sciatic, femoral or fascia iliaca blocks have not been shown to significantly reduce post-operative pain compared to controls.

Periarticular infiltration of local anesthetics has been shown in some settings to reduce pain during the immediate post-operative period (<24 h). However, no significant differences were noted in terms of early recovery or complications. The use of liposomal bupivacaine (LB) local infiltration decreased pain and shortened length of stay comparable to patients receiving a fascia iliaca compartment block, and has been shown in relatively few randomised trials to provide improved pain relief at 24 hours only compared to conventional bupivacaine. Continuous intra-articular infusion of bupivacaine after THA did not significantly further reduce post-operative pain compared to placebo.

In summary, the use of regional anesthesia when appropriate along with local anesthetic infiltration in the setting of a robust multimodal pain protocol minimises pain and complications while maximizing patient satisfaction following THA.

Introduction: Postoperative pain management following shoulder arthroscopy procedures is important, especially if they are to be performed as a day case surgeries. A variety of techniques are currently used to reduce postoperative pain such as patient controlled infusion pump and Interscalene block. Aim: In this study we evaluate the effect of Baxter elastomeric continuous infusion pump in managing pain following shoulder arthroscopy procedures. Methods & Materials: We prospectively reviewed thirty four patients who had shoulder arthroscopy procedures between January and July 2007. All patients had arthroscopic subacromial decompression. Baxter elastomeric infusion pump was used in all patients to provide postoperative pain relief. All patients had 10ml of 0.5% Marcaine as a bolus followed by 5ml/hr for 10 hours through the infusion pump. Visual analogue scale (VAS) was assessed at 4, 6,8 and 24 hours postoperatively. Discharge time and patients’ satisfaction were also assessed. Results: The Baxter elastomer pump provided effective pain relief postoperatively with median VAS(IQR) of 2.5(1.5–4.5), 2.5(1–5), 3(2–6), 6 (2–8) at 4, 6, 8 and 24 hours respectively. Our cohort had short hospital stay postoperatively with median (IQR) discharge time of 4.6 hours (3.5–5.3).Majority of patients reported that they are either very satisfied or satisfied with the pump. Conclusion: We conclude that Baxter Infusion Elastomer pump is effective in managing pain postoperatively following shoulder arthroscopy with a high patients’ satisfaction which resulted in a short hospital stay. It is simple to insert under direct visualisation ensuring adequate placement, simple to use and doesn’t require skilled nursing care. Also it has got less morbidity compared to other means which are used to provide postoperative pain relief such as interscalene block

Introduction. There is no consensus on the ideal pain management strategy following total hip arthroplasty (THA). This study sought to identify immediate changes in the hospital course of patients undergoing primary THA following implementation of a rapid recovery anesthesia and multimodal management of pain (RAMP) protocol. For this study, rapid recovery anesthesia describes the use of preoperative non-narcotic medication in conjunction with neuraxial anesthesia techniques confined to the operating room only. The multimodal pain regimen consists of pre- and post-operative high dose nonsteroidal anti-inflammatories (NSAIDs), gabapentin, and antiemetics with or without intraoperative periarticular anesthetic injection. We hypothesized that the implementation of a RAMP protocol would lead to decreased reported pain scores, decreased narcotic use, and a shorter hospital stay in patients undergoing primary THA. Methods. This retrospective cohort study performed at a multi-surgeon high-volume institution reviewed the records of 81 consecutive patients who underwent primary THA utilizing traditional anesthesia and an opioid-dependentpain management techniques between June to September 2014 compared to 78 patients who underwent primary THA after implementation of the RAMP protocol between November 2014 to February 2015. The length of stay (LOS), pain scores, narcotic use, and other clinical data were recorded for each study group. Equality of variance was confirmed prior to statistical analysis using t-test for equality of means. Results. There was no significant difference in the demographics, body mass index, ASA classification, or Charleson Comorbidity Index between the two cohorts. The average LOS was significantly shorter after implementation of the RAMP protocol with a mean of 2.10 ± 1.1 days versus 2.89 ± 1.0 days. Total amount of narcotics used was significantly less with the RAMP protocol (Fig 1). Patient reported pain scores were improved throughout the hospital stay with patients receiving the RAMP protocol reporting significantly less pain beginning the morning of POD 1 (Fig 2). No significant decrease in kidney function was seen following the use of high dose NSAIDs (p=0.18). Conclusions. The implementation of a RAMP protocol in patients undergoing primary total hip arthroplasty has resulted in an immediate shorter length of stay with less narcotics use and improved reported pain scores. To our knowledge, this is the first study demonstrating a statistically significantly shorter length of stay associated with a multimodal pain protocol. This study supports the benefits of broad implementation a RAMP protocol for total hip arthroplasty

Purpose of the study: Arthroscopic repair of rotator cuff tears is a painful technique. We conducted a randomized controlled trial to analyze prospectively the level of postoperative pain after this procedure and to assess the efficacy of three anti-pain techniques. Material and method: This prospective randomized study included 140 patients attending two centres specialized in shoulder surgery who underwent arthroscopic rotator cuff repair from January to November 2008. Preoperatively, patients were assigned to three anti-pain techniques: interscalenic catheter (KTIS) (n=44 patients), subacromial catheter (KTSA) (n=64 patients), unique subacromial injection of 2% ropivacaine (INJ) (n=32 patients). The procedure was performed under general anaesthesia in all cases. Criteria used to evaluate the efficacy of the anti-pain techniques were: pain as assessed by a visual analogue scale (VAS) the day before operation to the 30th postoperative day; daily consumption and total dose of opiates; subjective satisfaction with pain management assessed on day 30. Results: The pain profile was the same as demonstrated last year with a painful displacement on day 1 and progressive decline in pain through day 30 when the pain level was lower than preoperatively. Two risk factors were noted: isolated distal tears of the supraspinatus and concomitant acromioplasty. On day 0, the VAS was ≤ 1.7 in the KTIS group versus 3.6 and 3.5 respectively in the KTSA and INJ groups (p< 0.05). On day 1, the respective values were 3.1, 3.5 and 3.8 (NS). On day 2 and beyond, there was no difference between the three groups. Overall morphine consumption on day 0 was 10.8 mg in the INJ group versus 6.9 and 2.1 mg in the KTSA and KTIS groups, with a significant difference between the INJ and the KTIS groups. There was no difference beyond day 1. Patient satisfaction with pain management during the first 30 postoperative days reached 94.4, 82.9 and 84% respectively for INJ, KTIS and KTSA, with no statistically significant difference between the groups. Conclusion: The interscalenic catheter technique is more effective than the two other techniques. The subacromial catheter is not better than a single injection of local anaesthetic and is associated with greater risk, suggesting its use should be revisited

Over the past 30 years there have been many improvements in implant fixation, correction of deformity, improved polyethylene wear, and survival after knee replacement. The work over the last decade has focused on less invasive surgical techniques, multimodal pain management protocols, more rapid functional recovery and reduced length of stay, aiming to minimise the side effects of treatment while maintaining function and implant durability. When combined and standardised these pre-, intra- and post-operative factors have now facilitated outpatient knee replacement procedures for unicompartmental replacement, patella femoral arthroplasty and total knee replacement (TKR).

We have found liposomal bupivacaine, with potential for longer therapeutic action, to be a helpful adjunct and describe our current pain management program. The next step in our multimodal program is to improve the duration of patient satisfaction and reduce cost and length of stay after TKR.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):7–9.

Aims. Although periarticular injection plays an important role in multimodal pain management following total hip arthroplasty (THA), there is no consensus on the optimal composition of the injection. In particular, it is not clear whether the addition of a corticosteroid improves the pain relief achieved nor whether it is associated with more complications than are observed without corticosteroid. The aim of this study was to quantify the safety and effectiveness of cortocosteroid use in periarticular injection during THA. Methods. We conducted a prospective, two-arm, parallel-group, randomized controlled trial involving patients scheduled for unilateral THA. A total of 187 patients were randomly assigned to receive periarticular injection containing either a corticosteroid (CS group) or without corticosteroid (no-CS group). Other perioperative interventions were identical for all patients. The primary outcome was postoperative pain at rest during the initial 24 hours after surgery. Pain score was recorded every three hours until 24 hours using a 100 mm visual analogue scale (VAS). The primary outcome was assessed based on the area under the curve (AUC). Results. The CS group had a significantly lower AUC postoperatively at 0 to 24 hours compared to the no-CS group (AUC of VAS score at rest 550 ± 362 vs 392 ± 320, respectively; mean difference 158 mm; 95% confidence interval (CI) 58 to 257; p = 0.0021). In point-by-point evaluation, the CS group had significantly lower VAS scores at 12, 15, 18, 21, 24, and 48 hours. There were no significant differences in complication rates, including surgical site infection, between the two groups. Conclusion. The addition of corticosteroid to periarticular injections reduces postoperative pain without increasing complication rate following THA. Cite this article: Bone Joint J 2020;102-B(10):1297–1302

The importance of mitigating pain for patients undergoing total shoulder arthroplasty is extremely relevant for purposes of being able to initiate early functional rehabilitation and activities of daily living. The process, however, does not commence after surgery but rather before surgery. Careful patient education and instruction, including pre-operative exercises to maximise mobility, strength and endurance within the limited range of motion is quite helpful. Adjunctive therapy includes preemptive ultrasound-guided intrascalene regional anesthesia, immediate post-operative peri-incisional injection of liposomal bupivacaine, post-operative use of waterproof Tegaderm^TM dressing to allow warm showers early on in the rehabilitation period, peri-operative use of Cox 2 inhibitors and a gentle, therapist-guided passive exercise program focusing on relaxation techniques. This in combination with patient-controlled analgesic pumps, careful surgical technique providing adequate soft tissue releases and removal of potential pain generators such as the long tendon of the biceps and an arthritic AC joint all contribute to the minimization of the patient's pain experience, and offers relatively early weaning from parenteral narcotics in the first 24 hours, and oral narcotics within the first 7–10 days post-operatively.

Background. Although the aetiology of chronic low back pain (CLBP) is unknown, it is suggested that several subgroups among CLBP-patients might be identified who are likely to benefit from different interventions. The results of these interventions might be improved by matching interventions to patient characteristics. Purpose. The purpose of this longitudinal study is to determine which subgroup of CLBP-patients benefits most from the short, intensive pain management program of RealHealth_NL. Methods. A prospective cohort of 524 selected consecutive CLBP-patients was followed. Potential predictive indicators included demographic characteristics, functional disability, experienced pain and cognitive behavioural factors as measured at pre-treatment assessment. The outcome is defined as one year improvement in functional disability. A successful outcome is a value as seen in healthy populations. The two-week residential program is in line with recommendations in international guidelines, based on cognitive behavioural principles and delivered in collaboration with orthopedic spine surgeons. Results. Multivariate logistic regression revealed pre-treatment being employed (OR 3.609 [95%CI 1.795–7.256]), and functional disability (OR 0.943 [95%CI 0.921–0.965]) as significant predictive factors of a successful outcome in functional disability at one year follow-up. Conclusion. The results imply that CLBP-patients, who are employed, and less disabled at pre-treatment assessment, who participated in the RealHealth_NL program, are consistently associated with one year follow-up improvement of functional disability toward normal values. A small set of indicators is more easily identified and addressed and CLBP-patients who are more likely to benefit from the program could be given a higher entry priority. Conflict of Interest: J O'Dowd owns shares in RealHealth_NL; Research Development & Education independent research organisation; Sint Maartenskliniek health care provider and referral organisation. Source of funding: None. This abstract has not been previously published in whole or substantial part nor has it been presented previously at a national meeting

Introduction: The Royal College of anaesthetists in 2000 issued its recommendations about raising the standard in postoperative pain management. It recommended that 100% patients should be satisfied with the management of their pain and any side effects of analgesic treatment. We conducted this prospective study to compare effectiveness of combining local nerve blocks with PCA (patient controlled analgesia) morphine to PCA morphine only in controlling acute post operative pain among total knee arthroplasty patients. Patients and Methods: Prospective study from January 2002 till November 2003. It involves 50 Patients underwent total knee replacement. Average patient age 71y (range 53–83y). Patients divided into two groups: (A) – PCA (patient controlled analgesia) Morphine only and (B) – PCA. Morphine + local nerve Blocks. Data collected:. Pain score at 1,3,6,12,24 hrs after operation, Morphine used, Supplementary analgesia, Side effects (vomiting score), Patients satisfaction, Patients’ knee joint early range of movement and Patients average period of hospital stay. Results: Optimum pain control was 94% in group B compared with 78% in group A. Side effects was seen in 30% in group B compared to 45% in group A. There was no difference in the knee joint early range of movement. There was no difference in the patients’ average period of hospital stay. Conclusion: This study concludes that the pain relief, morphine usage, side effects and patient satisfaction are much better with PCA when combined with local nerve blocks than with PCA alone. We recommend that more total knee arthroplasty patients should be offered local nerve blocks in addition to their standard anaesthesia

The goals of any rehabilitation protocol should be to control pain, improve ambulation, maximise range of motion, develop muscle strength, and provide emotional support. Over 85% of TKA patients will recover knee function regardless of which rehabilitation protocol is adopted but the process can be facilitated by proper pain control, physical therapy, and emotional support. The remaining 15% of patients will have difficulty obtaining proper knee function secondary to significant pain, limited pre-operative motion, and/or the development of arthrofibrosis. This subset will require a special, individualised rehabilitation program, which may involve prolonged oral analgesia, continued physical therapy, more diagnostic studies and occasionally manipulation. Controlling pain is the mainstay of any treatment plan. The program described herein has been used at Ranawat Orthopaedics over the last 10 years in more than 2000 TKAs.

Previous research has suggested that when subjected to painful lumbar stimulation, chronic low back pain (CLBP) patients with illness behaviour (IB) are unable to effectively engage a sensory modulation system utilised by patients without IB. 1. Furthermore, reduced insular cortex volume in CLBP patients with IB, may compound this problem. 2. . Pain Management Programs (PMP) has demonstrated reductions in IB and disability associated with chronic pain conditions. This current study aims to assess whether the pattern of cerebral response to pain in IB patients could be normalised by participation in a PMP. 12 patients with CLBP and IB (>4/5 Waddell signs present) were recruited prior to attending a 16-day PMP. FMRI scanning occurred prior to (PrePMP) and upon completion of the PMP (PostPMP). 8 healthy volunteers (HC) were scanned once. As in previous research, painful stimuli consisted of intense electrical stimulation delivered bilaterally to the lower back. The presentation of 3 colours indicated the likelihood of receiving 10second stimulation to the lower back (Always, Never and Maybe). IB scores were significantly reduced PostPMP (p <0.05). FMRI group activation maps for the Always condition revealed PostPMP patients increased activation in posterior regions, areas similarly activated by HC. For the Maybe condition, compared to PrePMP group, HC demonstrated greater activation in precuneus and middle and inferior frontal regions. Compared to their pre-treatment selves, PostPMP patients demonstrated increased activation in posterior and frontal regions. The results demonstrate that completion of a 16-day PMP leads to alteration in the brain's response to painful low back stimulation in CLBP patients with IB. Increased activation is seen in regions associated with the top-down modulation of pain. The response is similar to that seen in HC, and greater than before PMP confirming that the PMP process facilitates the utilisation of more normal coping pathways in response to CLBP

Peri-articular injections (PAI) have become an important component in many multimodal pain protocols after total knee arthroplasty (TKA). Liposomal bupivacaine has emerged as a highly marketed and touted ingredient for PAI. However, the true efficacy of this material, particularly compared with less expensive PAI “cocktails” such as traditional bupivacaine or ropivacaine, has not been proven to date.

Ropivacaine is considered a long-active local analgesic and in combination with epinephrine, ketorolac and clonidine has been shown to be a very effective PAI in a multimodal pain program. Liposomal bupivacaine has been similarly touted as a long-acting PAI. Initial reports provided support for liposomal bupivacaine PAI's providing similar pain relief as epidurals or femoral nerve blocks. The authors of these studies tout comparable pain control with decreased length of stay attributable to avoiding the side effects of epidurals and regional blocks. However, the ultimate clinical issue relates to how liposomal bupivacaine PAI's compares to traditional PAI cocktail ingredients such as bupivacaine and ropivacaine, which also avoid deleterious effects of regional analgesia, and at a much cheaper price point. Fortunately the highest quality research to date, which includes randomised prospective trials and retrospective controlled cohort studies, have reported consistent results. In a retrospective cohort study comparing a traditional ropivacaine and epinephrine versus liposomal bupivacaine PAI demonstrated no difference between the two groups in inpatient pain scores when used in a comprehensive multimodal pain control program. Further, two prospective randomised trials reported no difference in liposomal bupivacaine PAI compared to a traditional PAI of either bupivacaine or ropivacaine, epinephrine, ketorolac and clonidine. Finally, there have been some authors who contend the efficacy of liposomal bupivacaine PAI's is entirely dependent on a meticulous injection technique, however, comparative studies against traditional PAI ingredients with this recommended technique do not exist.

In summary, the existing data supports that liposomal bupivacaine is an effective PAI that can be used to provide comparable pain relief to that achieved by regional blocks. However, liposomal bupivacaine has not been shown to provide superior pain relief when compared to traditional ropivacaine or bupivacaine PAI's in multimodal pain protocols after TKA. Further, liposomal bupivacaine is prohibitively priced at approximately six times that of ropivacaine-based PAI cocktails. Therefore, the “game changer” is likely the implementation of peri-articular injections as an essential component of multimodal pain control programs and NOT liposomal bupivacaine.

The goals of perioperative management are to relieve pain, achieve early mobilization after surgery, reduce length of hospital stay, and obtain adequate patient satisfaction. Several treatment options combining systemic analgesics and/or regional analgesia with or without opioids are available for postoperative pain; however, a gold standard has not been established although there is a progressive shift towards multimodal approaches to improve analgesia while minimizing opioid-related side effects.

EX-TRA-05 (DAVID-ART) was a randomised, double-blind, parallel, pivotal study, evaluating the analgesic efficacy and safety of the innovative oral combination of dexketoprofen/tramadol 25mg/75mg in comparison with the individual components (tramadol given at the higher dose of 100mg) on moderate to severe acute pain after total hip replacement. Repeated doses of study drug were administered every 8 hours and pain intensity (PI) was to be scored according to a 100mm visual analogue scale (VAS) on a programmed e-diary every 2 hours over a 56-hour period (i.e. along 7 repeated doses). A placebo arm was included at the first administration to validate the pain model. Rescue medication, metamizole 500mg, was available during the treatment period. The study primary endpoint was the mean sum of the pain intensity difference values throughout the first 8 hours (SPID₈), which considered the 3 active treatment arms and placebo (ITT population; N=641). In this phase, a clear superiority of the combination over the single agents was demonstrated (p<0.05). An additional analysis was performed during the entire 0–56h repeated-dose period excluding those patients who had received placebo at the first dose (N=161). The estimated mean (SE) differences on PI-VAS over 24, 32 and 56 hours post first dose (0–24h, 0–32h, and 0–56h) between the combination and each single agent were evaluated.

Patients who received active analgesic from the first dose (mITT population; N=480) were aged 29–80 years (42% were ≥65 years). At randomisation, pain was moderate (≥40–60mm) in 51% patients and severe (>60mm) in 49%. For dexketoprofen/tramadol, mean (SD) PI-VAS values were 22 (4.0) over 24 hours; 21 (4.1) over 32 hours; and 19 (3.8) over 56 hours. The estimated differences versus dexketoprofen 25mg and tramadol 100mg were respectively 10 (0.7) and 7.6 (0.7) over 24 hours; 9.8 (0.6) and 7.2 (0.6) over 32 hours; and 8.1 (0.5) and 6.3 (0.5) over 56 hours (p<0.0001 for all comparisons), which confirmed the superiority of the combination versus both single agents throughout the periods analysed.

This significant higher decrease of PI favouring dexketoprofen/tramadol 25mg/75mg over dexketoprofen 25mg and tramadol 100mg, all given every 8 hours, during the first 56 hours post dose confirmed the superior analgesia shown after the first 0–8h post-dose period. The combination of dexketoprofen/tramadol 25mg/75mg is able to provide a level of analgesia above that achievable by each component alone, with a sustained effect when used as a multiple-dose regimen. The addition of this new combo to the analgesic armamentarium may contribute to facilitate early mobilization after surgery, thus positively impacting perioperative co-morbidities and length of in-hospital stay.

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: The long term effects of treatment in a cohort of patients with chronic low back pain (CLBP) participating in an intensive pain management program. Background: Cognitive behavioral treatments produce clinically relevant benefits for patients with CLBP. Methods: The program provided by RealHealth-Netherlands is based on cognitive behavioral principles and executed in collaboration with orthopedic surgeons. Primary outcomes were daily functioning and self-efficacy. Measurements were at baseline, last day of residential program and at 1 and 12 months follow-up. A GLM procedure with repeated measures was applied to examine changes over time and to explore possible unwanted side effects. Effect sizes are analyzed using cohen’s d. Clinical relevance was examined using minimal clinical important differences (MCID) estimates for primary outcomes and quality of life. To compare results with literature Standardized Morbidity Ratios (SMR) were determined. Results: 107 patients with CLBP participated. Mean scores on primary and secondary outcomes showed a similar pattern: improvement immediately after following the program and maintenance of results over time. Effect sizes were 0.9 for functioning and 0.8 for self-efficacy. Clinical relevancy: 79% reached MCID on functioning, 53% on self-efficacy and 80% on quality of life. Found study results were 36% better and 2% worse when related to previous research on respectively rehabilitation programs and spinal surgery for similar conditions (SMR 136% and 98%respectively). Conclusion: The participants of this evidence based program learned to manage CLBP, improved in daily functioning and quality of life. The study results are comparable with results of spinal surgery and even better than results from less intensive rehabilitation programs. Conflict of Interest: None. Sources of Funding: None

Previous authors have suggested that the analgesic effects of intra-articular morphine may be beneficial. Clonidine has been found to potentiate the analgesic effect of morphine. Following knee arthroscopy, morphine has demonstrated equivocal effect in comparison to bupivicaine for analgesia while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine following hip arthroscopy. The purpose of this study was to evaluate the efficacy of intra-articular morphine in combination with clonidine on pain and narcotic consumption following hip arthroscopy surgery for femoroacetabular impingement.

A retrospective review was performed on 43 patients that underwent hip arthroscopy between September 2014 and May 2015 at our institution for femoroacetabular impingement. All patients received preoperative Celebrex and Tylenol per our anesthesia protocol, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 mcg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the two groups.

We found that patients who received intra-articular morphine and clonidine used significantly less opioid analgesic in the PACU, with 23 mEq of morphine equivalents required in the intra-articular morphine and clonidine group compared to 40 mEq of opiod equivalents in the non-injection group (p=0.0259). There were no statistically significant differences in time spent in recovery prior to discharge or in VAS pain scores recorded immediately post-operatively and at one hour following surgery.

In conclusion, we found that an intraoperative intra-articular injection of morphine and clonidine significantly reduced the amount of narcotic requirement following hip arthroscopy. We do believe that there may be significant benefits to this, including less systemic effects from overall narcotic usage in the perioperative period. Our study demonstrated a beneficial effect of intra-articular morphine that may help with overall pain improvement, less narcotic consumption, and improved patient satisfaction following outpatient hip arthroscopy. This study provides the foundation for future research currently being conducted in a randomised-control setting.

Bone marrow edema syndrome (BMES) of the femoral head in pregnant women is a very rarely seen disease with disabling pain in the hip, beginning in the second or third trimester and persisting after parturition. Although isolated BMES is generally considered to be a self-limiting disease, progression to irreversible avascular necrosis of the femoral head has occasionally been observed. The conservative standard treatment of BMES consists of analgesic or anti-inflammatory medication combined with reduced weight bearing and physiotherapy. Better results regarding pain reduction are achieved by surgical intervention, with core decompression being the current standard technique for the management of BMES.

The patients were aged between 31 and 43 years (mean 37.5 years). All patients presented with pain on effort, with gait disturbance and pain at rest starting in the third trimester of pregnancy at a mean gestational age of 28 weeks (25 to 32 weeks). Symptoms rapidly progressed over a 2-week period. We treated 4 postpartal women (6 hips) presenting femoral head BMES with infusions of the prostacycline analogue iloprost (20 μg for 5 days) followed by 3 weeks of partial weight-bearing. MRI was used to investigate the outcome of BMES.

Symptoms regressed rapidly during and after therapy. After 4 weeks all patients were asymptomatic with no limitations in ambulation. In the MRI assessment, complete regression of BMES could be detected in three patients and minor residual BMES in the femoral neck of one patient (one hip) after 3 months. Pain did not recur in any patient at a mean follow-up of 31 months (14–43 months).

The vasoactive drug iloprost has good analgesic potency in the treatment of postpartal women suffering from BMES and accelerates the natural course of the disease.