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. Materials and Methods. A prospective consecutive series of 217 patients undergoing shoulder surgery were studied. These were grouped into 10 groups. All procedures were arthroscopic apart from shoulder arthroplasty procedures such as hemiarthroplasty and total shoulder replacements (TSRs). The choice of regional anaesthesia was ISB with GA as standard practice. Visual analogue scores (VAS) at 0hrs, 1hr, 2hrs, 4hrs and 6hrs; and total opiates intake were recorded. A one-way single factor ANOVA was used as preferred statistical analytical method to determine whether there is a difference in VAS scores and total opiates intake amongst the groups. Postoperative analgesics were used for pain relief, although these were not standardised. Results. In total shoulder replacement group, although the RSR group used more morphine on average compared to the ASR group (Mean morphine intake 6.5mg vs 3mg), this was not statistically significant (F<Fcrit; p value= 0.19). When comparing all the arthroplasty groups, the difference in mean morphine intake was also statistically not significant (F<Fcrit; p value=0.24). However, when comparing all 10 groups’ morphine intake there was a statistically significant difference amongst these groups (F>F crit; p value=0.03). Interestingly, there was a statistically significant difference in VAS at 0hrs (F>Fcrit p value=0.01); 1hrs (F>Fcrit; p value=0.00), and at 6hrs (F>Fcrit; p value=0.02) when comparing all 10 groups. Conclusions. ISB is an effective technique in achieving pain control in shoulder surgery; however, there are still variations in analgesic needs amongst groups and the use of alternative techniques should be thus explored. A future prospective study looking at acute pain for a longer period of time after shoulder surgery would explore the effectiveness of ISB in achieving pain control consistent with rehabilitation requirements

Renal Osteodystrophy is a type of metabolic bone disease characterized by bone mineralization deficiency due to electrolyte and endocrine abnormalities. Patients with chronic kidney disease (CKD) are more likely to experience falls and fractures due to renal osteodystrophy and the high prevalence of risk factors for falls. Treatment involves medical management to resolve the etiology of the underlying renal condition, as well as management (and prevention) of pathological fractures. A 66-year-old female patient, with severe osteoporosis and chronic kidney disease undergoing haemodialysis, has presented with multiple fractures along the years. She was submitted to bilateral proximal femoral nailing as fracture treatment on the left and prophylactically due to pathological bone injury on the right, followed by revision of the left nail with a longer one after varus angulation and fracture distal to the nail extremity. Meanwhile, the patient suffered a pathological fracture of the radial and cubital diaphysis and was submitted to conservative treatment with cast, with consolidation of the fracture. Posteriorly, she re-fractured these bones after a fall and repeated the conservative treatment. Clinical management: There is a multidisciplinary approach to manage the chronic illness of the patient, including medical management to resolve the etiology and consequences of her chronic kidney disease, pain control, conservative or surgical fracture management and prevention of falls. The incidence of chronic renal disease is increasing and the patients with this condition live longer than previously and are more physically active. Thus, patients may experience trauma as a direct result of increased physical activity in a setting of weakened pathologic bone. Their quality of life is primarily limited by musculoskeletal problems, such as bone pain, muscle weakness, growth retardation, and skeletal deformity. A multidisciplinary approach is required to treat these patients, controlling their chronic diseases, managing fractures and preventing falls

Despite considerable legacy issues, Girdlestone's Resection Arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical comorbidities which preclude staged or significant surgical interventions, and / or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes. We reviewed all cases of GRA performed in our unit during an 8 year period, reviewing the demographics, indications, and information pertaining to previous surgeries, and post op outcome for each. Satisfaction was based on a binary summation (happy/unhappy) of the patients’ sentiments at the post-operative outpatient consultations. 13 cases were reviewed. They had a mean age of 75. The most common indication was PJI, with 10 cases having this indication. The other three cases were performed for avascular necrosis, pelvic osteonecrosis secondary to radiation therapy and end stage arthritis on a background of profound learning disability in a non-ambulatory patient. The average number of previous operations was 5 (1-10). All 13 patients were still alive post girdlestone. 7 (54%) were satisfied, 6 were not. 3 patients were diabetic. 5 patients developed a sinus tract following surgery. With sufficient pre-op patient education, early intensive physiotherapy, and timely orthotic input, we feel this procedure remains an important and underrated and even compassionate option in the context of massive lysis and / or the presence of pelvic discontinuity / refractory PJI. GRA should be considered not a marker of failure but as a definitive procedure that gives predictability to patients and surgeon in challenging situations

The risk of falls in patients undergoing orthopedic procedures is particularly significant in terms of health and socioeconomic effects. The literature analyzed closely this risk following procedures performed on the lower limb, but the implications following procedures on the upper limb remain to be investigated. Interestingly, it is not clear whether the increased risk of falling in patients undergoing shoulder surgery is due to preexisting risk factors at surgery or postoperative risk factors, such as anesthesiologic effects, opioid medications used for pain control, or brace use. Only one prospective study examined gait and fall risk in patients using a shoulder abduction brace (SAB) after shoulder surgery, revealing that the brace adversely affected gait kinematics with an increase in the risk of falls. The main purpose of the study was to investigate the influence of SAB on gait parameters in patients undergoing shoulder surgery. Patients undergoing elective shoulder surgery (arthroscopic rotator cuff repair, reverse total shoulder arthroplasty, and Latarjet procedure), who used a 15° SAB in the postoperative period, were included. Conversely, patients age > 65 years old, with impaired lower extremity function (e.g., fracture sequelae, dysmorphism, severe osteo-articular pathology), central and peripheral nervous system pathologies, and cardiac/respiratory/vascular insufficiency were excluded. Participants underwent kinematic analysis at four different assessment times: preoperative (T0), 24 hours after surgery (T1), 1 week after surgery (T2), and 1 week after SAB removal (T3). The tests used for kinematic assessment were the Timed Up and Go (TUG) and the 10-meter test (10MWT), both of which examine functional mobility. Agility and balance were assessed by a TUG test (transitions from sitting to standing and vice versa, walking phase, turn-around), while gait (test time, cadence, speed, and pelvic symmetry) was evaluated by the 10MWT. Gait and functional mobility parameters during 10MWT and TUG tests were assessed using the BTS G-Walk sensor (G-Sensor 2). One-way ANOVA for repeated measures was conducted to detect the effects of SAB on gait parameters and functional mobility over time. Statistical analysis was performed with IBM®SPSS statistics software version 23.0 (SPSS Inc., Chicago, IL, USA), with the significant level set at p<0.05. 83% of the participants had surgery on the right upper limb. A main effect of time for the time of execution (duration) (p=0.01, η2=0.148), speed (p<0.01, η2=0.136), cadence (p<0.01, η2=0.129) and propulsion-right (R) (p<0.05, η2=0.105) and left (L) (p<0.01, η2=0.155) in the 10MWT was found. In the 10MWT, the running time at T1 (9.6±1.6s) was found to be significantly longer than at T2 (9.1±1.3s, p<0.05) and at T3 (9.0±1.3s, p=0.02). Cadence at T1 (109.7±10.9steps/min) was significantly lower than at T2 (114.3 ±9.3steps/min, p<0.01) and T3 (114.3±9.3steps/min, p=0.02). Velocity at T1 (1.1±0.31m/s) was significantly lower than at T2 (1.2± 0.21m/s, p<0.05). No difference was found in the pelvis symmetry index. No significant differences were found during the TUG test except for the final rotation phase with T2 value significantly greater than T3 (1.6±0.4s vs 1.4±0.3s, p<0.05). No statistically significant differences were found between T0 and T2 and between T0 and T3 in any of the parameters analyzed. Propulsion-R was significantly higher at T3 than T1 (p<0.01), whereas propulsion-L was significantly lower at T1 than T0 (p<0.05) and significantly higher at T2 and T3 than T1 (p<0.01). Specifically, the final turning phase was significantly higher at T2 than T3 (p<0.01); no significant differences were found for the duration, sit to stand, mid-turning and stand to sit phases. The results demonstrated that the use of the abduction brace affects functional mobility 24 hours after shoulder surgery but no effects were reported at longer term observations

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

Background. Orthopedic trauma patients can have significant pain management requirements. Patient satisfaction has been associated with pain control and narcotic use in previous studies. Due to the multifactorial nature of pain, various injury patterns, and differences in pain tolerances the relationship between patient factors and narcotic requirements are poorly understood. The purpose of this study is to compare patient demographics for trauma patients requiring high doses of narcotics for pain control versus those with more minimal requirements. Methods. Our study sample included 300 consecutive trauma activations who presented to our emergency department during the 2015 calendar year. Opioids given to the patients during their hospital stay were converted to oral morphine equivalents using ratios available from the current literature. Patients were placed into two groups including those who were in the top 10% for average daily inpatient oral morphine equivalents and the other group was composed of the remaining patients. In addition to morphine equivalents, patient age, gender, injury severity score, length of stay, number of readmissions and urine toxicology results were also recorded. Injury severity score (ISS), morphine equivalents, and patient age were evaluated with the Shapiro-Wilk test of normality. Comparisons were performed with the Mann-Whitney U test. Between group comparisons for positive urine toxicology screen and gender were performed with Chi square and Fisher exact test. Pearson correlations were calculated between injury severity score, average daily oral morphine equivalents, and length of stay. P-value of 0.05 was used to represent significance. Statistical comparisons were made using SPSS version 23 (IBM, Aramonk, NY). Results. Median average daily morphine equivalents in the 10% of patients receiving the highest doses was 86.30 and 12.95 for the bottom 90%. The difference was statistically significant (p<0.001). The median ISS between the 2 groups was significant (p=0.018). There was no significant difference in age, readmission rate, and urine toxicology results. Patients in the top 10% were more likely to be male (p=0.003). Median length of stay for the top 10% group and bottom 90% group was 4 days and 2 days, respectively (p=0.005). No correlation between injury severity score and length of stay was found (p=0.475). A weak correlation of 0.115 was found between morphine equivalents and length of stay (p=0.047). Discussion. Our study shows male gender and ISS were correlated with higher oral morphine equivalents for the 10% of patients receiving the highest daily amounts when compared to the reaminder of the cohort. There was a significantly increased length of stay in the patients receiving higher narcotic doses. Whether this is due to ISS or increase in narcotics is unclear. However, positive correlation was not found between ISS and length of stay

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

Background. Pain control following knee replacement (TKR) surgery is often poor. Moderate to severe pain is often reported in the first 48 hours following surgery requiring opiate analgesia. The Local Infiltration Anaesthetic (LIA) technique has been described as a method to reduce post operative pain. In this study we report on our experience using LIA in addition to the PainKwell system (Peak Medical) of continuous infusion intra-articularly, of 0.25% bupivacaine at 4–5 mls/hour for 48 hours post surgery. The PainKwell catheter is placed in the knee joint during surgery. Methods. Between the June 2012 and Sep 2012, 62 patients undergoing primary TKR were prospectively followed up. All patients studied had spinal anaesthesia (SA) with diamorphine. Group 1. GA. No LIA and no PainKwell. 20 patients. Group 2. SA plus LIA plus PainKwell for 48 hours post operatively with catheter placed anteriorly under the patella. 21 patients. Group 3. SA plus LIA plus PainKwell for 48 hours post operatively with catheter placed posteriorly in the knee joint. 21 patients. Results. The patients without LIA or PainKwell required more morphine in the first 12 hours postoperative period than the other groups. Seventy percent (n=14) of these group 1 patients required 10mg morphine following TKR compared to only 2% (n=1) of patients requiring 10mg of morphine when LIA and PainKwell as used. The increased morphine requirement continued for 48 hours postoperatively in group 1, whereas none of the patients in groups 2 or 3 required morphine after 36 hours. Fewer patients suffered from nausea and vomiting or urinary retention in the group with LIA and PainKwell

Background. Hip arthroplasties are associated with high postoperative pain scores. In some reports, moderate to severe pain was 58% on the first day postoperatively in total hip replacements (THRs). Several techniques are currently used at our institution to tackle acute pain following THRs. These include: 1) Spinal anaesthetic (SA) with Diamorphine only; 2) General anaesthetic (GA) only; 3) SA with local infiltration anaesthetic mixture 1 (LIA1,). Mixture 1 consisted of ropivacaine, adrenaline, and ketorolac; 4) SA with LIA mixture 2 (LIA2). Mixture 2 consisted of bupivacaine and adrenaline; 5) SA with LIA1 and PainKwell pump system. In this study we report on the techniques of acute pain control following THR at our regional centre for elective primary THRs. Methods. Between June 2011 and July 2014, 173 consecutive patients undergoing primary THR using the posterior approach were prospectively followed up. Group 1. GA only. 31 patients, Group 2. SA only. 37 patients, Group 3. SA plus LIA1 only. 38 patients, Group 4. SA plus LIA2 only, 34 patients, Group 5. SA plus LIA1 plus PainKwell Pump System for 48 hours. 33 patients. Results. Fewer patients required opiate analgesia when LIA plus PainKwell pump system was used compared to the other groups. The highest significance was at 0–12 hrs for patients requiring up to 20mg morphine usage (χ2(2) = 46.713, p = 0.000); and 0–12hrs for patients requiring 30mg morphine usage (χ2(2) = 46.310, p = 0.000). There were no infections, DVTs or PEs in any group. One patient in group 3 suffered a stroke (ASA 4). A Kruskal-Wallis H test also showed that there was a statistically significant difference in morphine usage across groups 1, 2, 3, 4, and 5. Conclusion. We recommend the use of LIA with PainKwell pump system continuous infusion as an efficacious method to control pain following THR

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total knee replacement (TKR). To assess the effectiveness of peri-operative LAI for pain management in patients receiving TKR we conducted a systematic review, fully powered randomised controlled trial (RCT) and economic evaluation. We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving TKR. Two reviewers screened abstracts and extracted data. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. Authors were contacted if required. When feasible, we conducted meta-analysis with studies analysed separately if a femoral nerve block (FNB) was provided. In the APEX RCT, we randomised 316 patients awaiting TKR to standard anaesthesia which included FNB, or to the same regimen with additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline). Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation. Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires. In the systematic review, 23 studies including 1,439 patients were identified. Compared with patients receiving no intervention, LAI reduced WOMAC-Pain by standardised mean difference (SMD) −0.40 (95%CI −0.58, −0.22; p<0.001) at 24 hours at rest and by SMD −0.27 (95%CI −0.50, −0.05; p=0.018) at 48 hours during activity. In three studies there was no difference in pain at any time point between randomised groups where all patients received FNB. Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Few studies reported long-term outcomes. In the APEX RCT, pain levels in hospital were broadly similar between groups. Overall opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. There were no differences in pain outcomes between groups at 12 months. In the economic evaluation, LAI was marginally associated with lower costs. Using the NICE £20,000 per QALY threshold, the incremental net monetary benefit was £264 (95%CI, −£710, £1,238) and the probability of being cost-effective was 62%. Although LAI appeared to have some benefit for reduced pain in hospital after TKR there was no evidence of pain control additional to that provided by femoral nerve block, however it would be cost-effective at the current NICE thresholds

Local infiltration analgesia is a relatively novel technique developed for effective pain control following total knee replacement, reducing requirements of epidural or parenteral post-operative analgesia. The study aimed to investigate the anatomical spread of Local Infiltration Analgesia (LIA) used intra-operatively in total knee arthroplasty (TKA) and identify the nerve structures reached by the injected fluid. Six fresh-frozen cadaveric lower limbs were injected with 180ml of a solution of latex and India ink to enable visualisation. Injections were done according to our standardised LIA technique. Wounds were closed and limbs were placed flat in a freezer at −20°C for two weeks. Limbs were then either sliced or dissected to identify solution locations. Injected solution was found from the proximal thigh to the middle of the lower leg. The main areas of concentration were the popliteal fossa, the anterior aspect of the femur and the subcutaneous tissue of the anterior aspect of the knee. There was less solution in the lower popliteal fossa. The solution was found to reach the majority of the terminal branches of the tibial, fibular and obturator nerves. Overall, there was good infiltration of nerves supplying the knee. The lack of infiltration into the lower popliteal fossa suggests more fluid or a different injection point could be used. The solution that travelled distally to the extensor muscles of the lower leg probably has no beneficial analgesic effect for a TKA patient. This LIA technique reached most nerves that innervate the knee joint which supports the positive clinical results from this LIA technique. However, there may be scope to optimise the injection sites

We aimed to determine the impact of anaesthetic techniques on post-operative analgesic utilisation in people undergoing total knee arthroplasty. We conducted a prospective study at a district general hospital to assess post-operative analgesia use via patient controlled analgesia (PCA) in patients undergoing a elective total knee arthroplasty. Subjects were divided into three groups; group 1 (general anaesthetic and local nerve block, n = 39), group 2 (spinal only, n= 39) and group 3 (general anaesthetic only, n = 38). The primary outcome measure was post-operative morphine consumption through a PCA within the first 24 hours. All subjects were followed up post-operatively by a dedicated pain control nurse. Data was analysed using SPSS version 17 for Windows (SPSS Inc, Chicago, IL, USA). Results are reported as mean (SD) unless stated otherwise. No significant difference in the age or sex distribution between groups was demonstrable. There was no statistical difference in the average usage of morphine when comparing Group 1 compared to group 2, (77.57 (49.56) vs 65.80 (44.71), p=0.27), group 1 compared to group 3, (77.57 (49.56) vs 77.80 (45.52) p=0.98) and finally group 2 compared to group 3, (65.80 (44.71) vs 77.80 (45.52), p=0.25). In this cohort of patients undergoing total knee arthroplasty the anaesthetic technique used does not appear to have an influence on the post-operative pain management

Background. Back pain is a common orthopaedic problem which results in hospital admissions in severe cases. The aim of our study was to identify the reasons for back pain admissions and role of further investigations in the treatment of severe back pain. Methods. We collected data prospectively for all admissions between January and March 2011. Demographic details were recorded along with the reasons for admissions, time of admission, further investigations and treatment offered. Results. Total admissions were 850 and 58 (6.8%) had severe back pain.13 patients (22%) had fractures (Group-A); 16 patients (27%) did not require MRI scan (Group-B); 27 patients (50%) needed MRI scan of the lumbosacral spine (Group-C). The mean age of Group-A was 67 years (15–93). 3 were male and 10 females. 10 patients had lumbar and 3 had thoracic spine fractures. The mean age of Group-B was 59 years (32–87). 8 were male and 8 females. The mean age of Group-C was 47 years (23–79). 9 were male and 18 females. The mean hospital stay for Group-C was 5days (0–29). 16 patients (59%) were referred by GP, 5(18%) by emergency department and 3(11%) by physiotherapist. 9(43%) were admitted for pain control, 8(38%) with suspected Cauda Equina syndrome and 2(9%) for further investigations. 20 patients (83%) were admitted during the day, 3(12%) in the evening and 1(4%) during the night. No patient had Cauda equina syndrome on clinical and radiological examination. 12 patients(44%) had nerve root compression on the MRI scan and 7(58%) were offered surgery. Conclusions. Patients were older in group-A with a mean age of 67 years. 27% did not require MRI scan. 67% females admitted with back pain required an MRI scan. No patient had Cauda Equina Syndrome. 55% patients had no nerve root compression. MRI scan was performed to reassure the patients and clinicians with negative results in the presence of severe back pain and unclear neurological signs. Conflicts of interest. None. Sources of funding. None

Objectives

We investigated the effects on fracture healing of two up-regulators of inducible nitric oxide synthase (iNOS) in a rat model of an open femoral osteotomy: tadalafil, a phosphodiesterase inhibitor, and the recently reported nutraceutical, COMB-4 (consisting of L-citrulline, Paullinia cupana, ginger and muira puama), given orally for either 14 or 42 days.

Ketamine has been used in combination with a variety of other agents for intra-articular analgesia, with promising results. However, although it has been shown to be toxic to various types of cell, there is no available information on the effects of ketamine on chondrocytes. We conducted a prospective randomised controlled study to evaluate the effects of ketamine on cultured chondrocytes isolated from rat articular cartilage. The cultured cells were treated with 0.125 mM, 0.250 mM, 0.5 mM, 1 mM and 2 mM of ketamine respectively for 6 h, 24 hours and 48 hours, and compared with controls. Changes of apoptosis were evaluated using fluorescence microscopy with a 490 nm excitation wavelength. Apoptosis and eventual necrosis were seen at each concentration. The percentage viability of the cells was inversely proportional to both the duration and dose of treatment (p = 0.002 and p = 0.009). Doses of 0.5 mM, 1 mM and 2mM were absolutely toxic. We concluded that in the absence of solid data to support the efficacy of intra-articular ketamine for the control of pain, and the toxic effects of ketamine on cultured chondrocytes shown by this study, intra-articular ketamine, either alone or in combination with other agents, should not be used to control pain. Cite this article: Bone Joint J 2014; 96-B:989–94

We compared time-dependent changes in the biomechanical properties of single-and double-row repair of a simulated acute tear of the rotator cuff in rabbits to determine the effect of the fixation techniques on the healing process.

A tear of the supraspinatus tendon was created in 80 rabbits which were separated into two equal groups. A single-row repair with two suture anchors was conducted in group 1 and a double-row repair with four suture anchors in group 2. A total of ten intact contralateral shoulder joints was used as a control group. Biomechanical testing was performed immediately post-operatively and at four and eight weeks, and histological analysis at four and eight weeks.

The mean load to failure in group 2 animals was greater than in group 1, but both groups remained lower than the control group at all intervals. Histological analysis showed similar healing properties at four and eight weeks in both groups, but a significantly larger number of healed tendon-bone interfaces were identified in group 2 than in group 1 at eight weeks (p < 0.012).

The ultimate load to failure increased with the number of suture anchors used immediately post-operatively, and at four and eight weeks. The increased load to failure at eight weeks seemed to be related to the increase in the surface area of healed tendon-to-bone in the double-row repair group.