Introduction and Objective. Continuous peripheral nerve blocks (cPNBs) have shown good results in pain management after orthopedic surgeries. However, the variation of performance between different subspecialities is unknown. The aim of this study is to describe our experience with cPNBs after lower limb orthopedic surgeries in different subspecialties. Materials and Methods. This prospective cohort study was performed on collected data from cPNBs after orthopedic surgeries in lower limbs. Catheters were placed by experienced anesthesiologists using sterile technique. After catheterization, the patients were examined daily, by specially educated acute pain service nurses. The characteristics of the patients, duration of catheterization, severity of the post-operative pain, need for additional opioids, and possible complications were registered. Results. We included 246 patients (=547 catheters). 115 (21%) femoral, 162 (30%) saphenous, 66 (12%) sciatic, and 204 (37%) popliteal sciatic nerve catheter were used. The median duration of a catheter was 3 days [IQR = 2 – 5]. The proportion of femoral, sciatic, saphenous, and popliteal nerve catheters with duration of more than two days was 81%, 79%, 73%, and 71% for, respectively. This proportion varied also between different subspecialties. 91% of the catheters remained in place for more than two days in amputations (n=56), 89% in pediatric surgery (n=79), 76% in trauma (n=217), 64% in foot and ankle surgery (n=129), and 59% in limb reconstructive surgery (n=66). The proportion of pain-free patients were 77 – 95% at rest, 63 – 88% at mobilization. 79 – 92% did not need increased opioid doses, and 50 – 67% did not require PRN opioid. 443 catheters (81%) were removed as planned. The cause of unplanned catheter removal was loss of efficacy in 69 (13%), dislodgement in 23 (4.2%), leakage in 8 (1.5%), and erythema in 4 catheters (0.73%). No major complication occurred. Conclusions. 81% of catheters remained in place until planned removal and opioid usage after surgery was lower than expected. Catheters were efficient in both adult and pediatric surgery; however, a variation was seen between orthopaedic subspecialities regarding duration of nerve catheter usage

Determine the infection risk of nonoperative versus operative repair of extraperitoneal bladder ruptures in patients with pelvic ring injuries. Pelvic ring injuries with extraperitoneal bladder ruptures were identified from a prospective trauma registry at two level 1 trauma centers from 2014 to 2020. Patients, injuries, treatments, and complications were reviewed. Using Fisher's exact test with significance at P value < 0.05, associations between injury treatment and outcomes were determined. Of the 1127 patients with pelvic ring injuries, 68 (6%) had a concomitant extraperitoneal bladder rupture. All patients received IV antibiotics for an average of 2.5 days. A suprapubic catheter was placed in 4 patients. Bladder repairs were performed in 55 (81%) patients, 28 of those simultaneous with ORIF anterior pelvic ring. The other 27 bladder repair patients underwent initial ex-lap with bladder repair and on average had pelvic fixation 2.2 days later. Nonoperative management of bladder rupture with prolonged Foley catheterization was used in 13 patients. Improved fracture reduction was noted in the ORIF cohort compared to the closed reduction external fixation cohort (P = 0.04). There were 5 (7%) deep infections. Deep infection was associated with nonoperative management of bladder rupture (P = 0.003) and use of a suprapubic catheter (P = 0.02). Not repairing the bladder increased odds of infection 17-fold compared to repair (OR 16.9, 95% CI 1.75 – 164, P = 0.01). Operative repair of extraperitoneal bladder ruptures substantially decreases risk of infection in patients with pelvic ring injuries. ORIF of anterior pelvic ring does not increase risk of infection and results in better reductions compared to closed reduction. Suprapubic catheters should be avoided if possible due to increased infection risk later. Treatment algorithms for pelvic ring injuries with extraperitoneal bladder ruptures should recommend early bladder repair and emphasize anterior pelvic ORIF

The current study aims to find the role of Enhance Recovery Pathway (ERP) as a multidisciplinary approach aimed to expedite rapid recovery, reduce LOS, and minimize morbidity associated with Non Fusion Anterior Scoliosis Correction (NFASC) surgery. A retrospective analysis of 35 AIS patients who underwent NFASC with Lenke 1 and Lenke 5 curves with a minimum of 1 year of follow-up was done. Patient demographics, surgical details, postoperative analgesia, mobilization, length of stay (LOS), patient satisfaction survey score with respect to information and care, and 90 days complications were collected. The cohort included 34 females and 1 male with a mean age of 15.2 years at the time of surgery. There were 16 Lenke 1 and 19 Lenke 5 in the study. Mean preoperative major thoracic and thoracolumbar/lumbar Cobb's angle were 52˚±7.6˚ and 51˚±4.5˚ respectively. Average blood loss and surgical time were 102 ±6.4 ml and 168 ± 10.2 mins respectively. Average time to commencing solid food was 6.5±1.5 hrs. Average time to mobilization following surgery was 15.5± 4.3 hrs. The average duration to the stopping of the epidural was 42.5±3.5 hrs. The average dose of opioid consumption intraoperatively was 600.5±100.5 mcg of fentanyl i.v. and 12.5±4.5 mg morphine i.v. Postoperatively opioids were administered via an epidural catheter at a dose of 2 mg of morphine every 24 hours up to 2 days and an infusion of 2mcg/hr of fentanyl along with 0.12-0.15% ropivacaine. The average duration to transition to oral analgesia was 55.5±8.5 hrs .20 patients had urinary catheter and the average time to removal of the catheter was 17.5±1.4 hrs. 25 patients had a chest tube and the average time to remove of chest tube was 25.5±3.2 hrs. The average length of hospital stay was 3.1±0.5 days. No patient had postoperative ileus or requirement of blood transfusion or any other complications. No correlation was found between LOS and initial cobb angle. The application of ERP in AIS patients undergoing NFASC results in reduced LOS and indirectly the cost, reduced post-operative opioid use, and overall improve patient satisfaction score

Acute post-operative urinary retention (POUR) is a recognized complication following lower limb arthroplasty. Its occurrence may have patient and ultimately medico-legal implications. Identifying high-risk patients and the associated risk factors pre-operatively, is vital to tackle this issue and reduce its occurrence, which ultimately, may enhance the overall success of our operations. Our aim was to assess the incidence of POUR following elective lower limb arthroplasty and analyze the related factors that could potentially predict the likelihood of developing POUR in our patient cohort. A prospective audit of 158 patients was conducted in our department. POUR was defined as inability to pass urine voluntarily within the first 24 hours following elective lower limb arthroplasty leading to the insertion of a urinary catheter. Surgical-related factors including intra-operative fluid use, type of spinal anesthetic, duration of surgery, time from surgery till insertion of a urinary catheter as well as patient-related factors including medication, urological history and Body Mass index (BMI) was collected and analyzed. 21 (13.3%) patients developed post-operative urinary retention, 11 (52%) and 10 (48%) following knee and hip replacements respectively. Of which, 19 (90.5%) were male and 2 (9.5%) were female with an average age of 66 yrs. 13 (62%) had a previous urological history and 10 (48%) were on retention associated medication. Bupivacaine as a spinal anesthetic was associated with an increased risk of developing post-operative urinary retention. The average time till catheter insertion was 14 hrs. Only 2 (10%) had an unsuccessful TWOC on discharge. Bupivacaine as a spinal anesthetic and a previous urological history can be considered as risk factors for the development of POUR. Pre-operative urinary catheterization should be considered in this high-risk group of patients

Abstract. Objectives. Acute compartment syndrome (ACS) is a progressive form of muscle ischaemia that is a surgical emergency and can have detrimental outcomes for patients if not treated optimally. The current problem is that there is no clear diagnostic threshold for ACS or guidance as to when fasciotomies should be performed. A new diagnostic method(s) is necessary to provide real-time information about the extent of muscle ischaemia in ACS. Given that lactic acid is produced by cells through anaerobic respiration, it may be possible to measure H+ ion concentration and to use this as a measure of ischaemia within muscle. Although we are familiar with the key biochemical metabolites involved in ischaemia; and the use of viability dyes in cell culture to distinguish between living or dead cells is well recognised; research has not been undertaken to correlate the biochemical and histological findings of ischaemia in skeletal muscle biopsies. Our primary aim was to investigate the potential for viability dyes to be used on live skeletal muscle biopsies (explants). Our secondary aim was to correlate the intramuscular pH readings with muscle biopsy viability. Methods. Nine euthanised Wistar rats were used. A pH catheter was inserted into one exposed gluteus medius muscles to record real-time pH levels and muscle biopsies were taken from the contralateral gluteus medius at the start of experiment and subsequently at every 0.1 of pH unit drop. Prior to muscle biopsy, the surface of the gluteus medius was painted with a layer of 50µmol/l Brilliant blue FCF solution to facilitate biopsy orientation. A 4mm punch biopsy tool was used to take biopsies. Each muscle biopsy was placed in a base mould filled with 4% ultra-low melting point agarose. The agarose embedded tissue block was sectioned to generate 400 micron thick tissue slices with a vibratome. The tissue slices were then placed in the staining solution with Hoechst 33342, Ethidium homodimer-1 and Calcein am. The tissue slices were imaged with Zeiss LSM880 confocal microscope's Z stack function. A dead muscle control was created by adding TritonX-100 to other tissue slices. For quantitative analyses, the images were analysed in Image J using the selection tool. This permitted individual cells to be identified and the mean grey value of each channel to be defined. Using the dead control, we were able to identify the threshold value for living cells using the Calcein AM channel. Results. Viability dyes, used primarily for cell cultures, can be used with skeletal muscle explants. Our study also showed that despite a significant reduction in tissue pH concentration over time, that almost 100% of muscle cells were still viable at pH 6.0, suggesting that skeletal muscle cells are robust to hypoxic insult in the absence of reperfusion. Conclusions. Viability dyes can be used on skeletal muscle biopsies. Further research investigating the likely associations between direct measured pH using a pH catheter, the concentrations of key cellular metabolic markers, and muscle tissue histology using vitality dyes in response to ischaemia, rather than hypoxia, is warranted. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Scoliosis correction surgery is one of the longest and most complex procedures of all orthopedic surgery. The complication rate is therefore not negligible and is particularly high when the surgery is performed in patients with neuromuscular or connective tissue disease or complex genetic syndromes. In fact, these patients have various comorbidities and organ deficits (respiratory capacity, swallowing / nutrition, heart function, etc.), which can compromise the outcome of the surgery. In these cases, an accurate assessment and preparation for surgery is essential, also making use of external consultants. To make this phase simpler, more effective and homogeneous, a multidisciplinary path of peri-operative optimization is being developed in our Institute, which also includes the possibility of post-operative hospitalization for rehabilitation and recovery. The goal is to improve the basic functional status as much as possible, in order to ensure faster functional recovery and minimize the incidence of peri-operative complications, to be assessed by clinical audit. The path model and the preliminary results on the first patients managed according to the new modality are presented here. The multidisciplinary path involves the execution of the following assessments / interventions: • Pediatric visit with particular attention to the state of the upper airways and the evaluation of chronic or frequent inflammatory states • Cardiological Consultation with Echocardiogram. • Respiratory Function Tests, Blood Gas Analysis and Pneumological Consultation to evaluate indications for preoperative respiratory physiotherapy cycles, Non-Invasive Ventilation (NIV) cycles, Cough Machine. Possible Polysomnography. • Nutrition consultancy to assess the need for nutritional preparation in order to improve muscle trophism. • Consultation of the speech therapist in cases of dysphagia for liquids and / or solids. • Electroencephalogram and Neurological Consultation in epileptic patients. • Physiological consultation in patients already being treated with a cough machine and / or NIV. • Availability of postoperative hospitalization in the rehabilitation center (with skills in respiratory and neurological rehabilitation) for the most complex cases. When all the appropriate assessments have been completed, the anesthetist in charge at our Institute examines the clinical documentation and establishes whether the path can be considered complete and whether the patient is ready for surgery. At the end of the surgery, the patient is admitted to the Post-operative Intensive Care Unit of the Institute. If necessary, a new program of postoperative rehabilitation (respiratory, neuromotor, etc.) is programmed in a specialist reference center. To date, two patients have been referred to the preoperative optimization path: one with Ullrich Congenital Muscular Dystrophy, and one with 6q25 Microdeletion Syndrome. In the first case, the surgery was performed successfully, and the patient was discharged at home. In the second case, after completing the optimization process, the surgery was postponed due to the finding of urethral malformation with the impossibility of bladder catheterization, which made it necessary to proceed with urological surgery first. The preliminary case series presented here is still very limited and does not allow evaluations on the impact of the program on the clinical practice and the complication rate. However, these first experiences made it possible to demonstrate the feasibility of this complex multidisciplinary path in which a network of specialists takes part

Abstract. Background. Progressive muscle ischaemia results in reduced aerobic respiration and increased anaerobic respiration, as cells attempt to survive in a hypoxic environment. Acute compartment syndrome (ACS) is a progressive form of muscle ischaemia that is a surgical emergency resulting in the production of Lactic acid by cells through anaerobic respiration. Our previous research has shown that it is possible to measure H+ ions concentration (pH) as a measure of progressive muscle ischaemia (in vivo) and hypoxia (in vitro). Our aim was to correlate intramuscular pH readings and cell viability techniques with the intramuscular concentration of key metabolic biomarkers [adenosine triphosphate (ATP), Phosphocreatine (PCr), lactate and pyruvate], to assess overall cell health in a hypoxic tissue model. Methods. Nine euthanised Wistar rats were used in a non-circulatory model. A pH catheter was used to measure real-time pH levels from one of the exposed gluteus medius muscles, while muscle biopsies were taken from the contralateral gluteus medius at the start of the experiment and subsequently at every 0.1 of a pH unit decline. The metabolic biomarkers were extracted from the snap frozen muscle biopsies and analyzed with standard fluorimetric method. Another set of biopsies were stained with Hoechst 33342, Ethidium homodimer-1 and Calcein am and imaged with a Zeiss LSM880 confocal microscope. Results. Our study shows that the direct pH electrode readings decrease with time and took an average of 69 minutes to drop to a pH of 6.0. The concentrations of ATP, pyruvate and PCr declined over time, and the concentration of lactate increased over time. At pH 6.0, both ATP and PCr concentrations had decreased by 20% and pyruvate has decreased by 50%, whereas lactate had increased 6-fold. The majority of cells were still viable at a pH of 6.0, suggesting that skeletal muscle cells are remarkably robust to hypoxic insult, although this was a hypoxic model where reperfusion was not possible. Conclusions. Our research suggests that histologically, skeletal muscle cells are remarkably robust to hypoxic insult despite the reduction in the total adenine nucleotide pool, but this may not reflect the full extent of cell injury and quite possibly irreversible injury. The timely restoration of blood flow in theory should halt the hypoxic insult, but late reperfusion results in cellular dysfunction and cell death due to localised free radical formation. Further research investigating the effects of reperfusion in vivo are warranted, as this may identify an optimal time for using pharmacological agents to limit reperfusion injury, around the time of fasciotomy to treat acute compartment syndrome. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

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

Summary. Coagulase-negative staphylococci, including S. epidermidis, have emerged as the leading pathogens of hospital-acquired biomaterial-related infections. These infections can be clinically indolent and challenging also for diagnostic imaging. In the current model of catheter-related infections, . 68. Ga-labeled Siglec-9 PET/CT imaging was able to detect peri-implant S. epidermidis bone infections. Introduction. Coagulase-negative staphylococci, including S. epidermidis, have emerged as the leading pathogen of nosocomial (hospital-acquired) biomaterial-related infections, including periprosthetic infections and intravascular catheter-related bloodstream infections. Pathogenic S. epidermidis strains exhibit robust attachment to implant surfaces and subsequent biofilm formation. By nature, the clinical picture of periprosthetic S. epidermidis infections can be indolent with vague signs of infection. These infections are also highly challenging for diagnostic imaging and microbiologic studies. Our recent experimental study of . 18. F-FDG-PET/CT confirmed that subacute peri-implant S. epidermidis infections, reflecting limited inflammatory reaction, are characterised by low . 18. F-FDG uptake. Vascular adhesion protein-1 (VAP-1) is an inflammation inducible endothelial protein, which controls leukocyte migration to sites of inflammation and infection. Siglec-9 is a leukocyte ligand of VAP-1. We hypothesised that . 68. Ga-labeled Siglec-9, developed for PET imaging of inflammation and cancer, could be a novel tracer also for early defection of S. epidermidis peri-implant bone infections. Material & Methods. Thirty adult male Sprague-Dawley rats were randomised into three groups (n=10/group). A clinical intravenous polymer catheter was introduced into the medullary cavity of the left tibia followed by injections of a clinical isolate of S. epidermidis (T-54580, 3 × 10. 8. CFU/mL) and an adjunct sodium morrhuate. In the positive control group, a clinical isolate of S. aureus (52/52A/80, 3 × 10. 5. CFU/mL) with sodium morrhuate was injected. In the negative control group, equal amount of sterile saline was injected via the catheter. The catheter, cut at the level of tibial tuberosity, was left in situ to serve as the implant. Two weeks after surgery, PET imaging with . 68. Ga-DOTA-Siglec-9 was performed with quantitative analysis of the standardised uptake value (SUV) in the region of interests both in vivo and ex vivo. SUV ratio between the operated and contralateral intact tibia was calculated. The presence of infections and the absence of contamination in the negative control group were verified by separate microbiological analyses of bone samples and retrieved implants. The presence of microbial biofilms on catheters was verified ex vivo with fluorescence microscope. Histologic inflammatory reaction was graded using a scoring system. Intergroup differences were tested by means of ANOVA with a post-hoc test. Results. Both staphylococcal strains caused histologically acute osteomyelitic changes. In . 68. Ga-DOTA-Siglec-9 PET/CT imaging of the negative control group, there was a significant difference (29.5%, p<0.001) in the SUV ratio of the operated and contralateral tibia, demonstrating aseptic inflammatory reaction to catheter implantation. The corresponding SUV ratio values were 58.1% in the S. epidermidis group and 41.7% in the S. aureus group. The uptake in the S. epidermidis group was significantly (p=0.009) higher than in the negative control group. Discussion/Conclusion. The animal model was reproducible in creation of culture-positive biomaterial-related infections. . 68. Ga-labeled Siglec-9 PET/CT imaging was able to demonstrate aseptic inflammation in the negative control group and the tracer also detected peri-implant bone infections caused by S. epidermidis

Decreased oxygenation and delayed wound healing may negate the advantages of using a medial parapatellar incision in Total Knee Replacement. Tissue biochemical and blood flow data are not currently available in the literature. 20 patients were included in the study and randomised to midline or medial parapatellar skin incision groups, being supervised by one of 3 Consultant surgeons. Cutaneous blood flow was measured using a Speckle Contrast Blood Perfusion Imager at pre-operative and Days 1 & 3 post-operative intervals. Interstitial fluid measurements for lactate, pyruvate, lactate/pyruvate ratio and glucose were obtained from subcutaneous catheters with a dialysis membrane. Pre-operative samples were obtained from a catheter inserted into the prospective lateral wound edge. A catheter inserted after wound closure supplied dialysates at 0.5, 1, 2, 4, 6, 12 and 24-hour intervals. One catheter was corrupted on insertion; therefore the patients with biochemical data numbered 19. Cutaneous blood flow improved over the 3 post-operative days in both types of incision and both sides, the medial retaining comparatively better flow. At Day 3, the parapatellar incision group displayed better flow on both sides of the wound. The concentration of lactate was highest in the parapatellar incision group of patients at all intervals. Pyruvate concentrations did not appear to differ across the incision types. Similarly, glucose concentrations did not appear to differ until after 4 hours, when higher concentrations were recorded in the midline group. Lactate/pyruvate ratio appeared to be notably greater in the parapatellar incision group. Plotting change in blood flow relative to change in lactate concentration demonstrated an increase in lactate as flow deteriorates. The study findings suggest medial parapatellar incisions have increased anaerobic metabolites due to tissue hypoperfusion. Previous studies have demonstrated decreased oxygen tension in lateral based flaps and more recently the medial to lateral arterial anatomy has been demonstrated

Introduction and Objective. In multiple trauma patients, as well as in the healing of isolated fractures (Fx) with heavy bleeding (trauma haemorrhage, TH), complications occur very often. This is particularly evident in elderly patients over 65 years of age. Since these accompanying circumstances strongly influence the clinical course of treatment, the influence of age on bone regeneration after femoral fracture and severe blood loss was investigated in this study. Materials and Methods. 12 young (17–26 weeks) and 12 old (64–72 weeks) male C57BL / 6J mice per group were examined. The fracture group Fx underwent an osteotomy after applying an external fixator. The THFx group also received blood pressure-controlled trauma hemorrhage (35 mmHg for 90 minutes) and reperfusion with Ringer's solution for 30 minutes. The Sham group received only the catheter and one external fixator. μCT scans of the femora were performed in vivo after 2 weeks and ex vivo after 3 weeks. Histological and biomechanical examinations were also carried out. The statistical significance was set at p ≤ 0.05. The non-normally distributed data were analyzed using the Mann-Whitney-U or Kruskal-Wallis test. Results. The histology showed less mineralized bone in the fracture gap in old animals of the Fx (25.41% [1.68%]) and THFx groups (25.50% [4.07%]) compared with the young ones (34.20% [6.36%], p = 0.003; 34.31% [5.12%], p=0.009). Moreover, a severe blood loss lead to more cartilage in both young (6.91% [5.08%]) and old animals (4.17% [1.42%]) compared to animals with only a fracture (2, 45% [1.04%], p=0.004; 2.95% [1.12%], p=0.032). In old animals (11.37 / nm. 2. [17.17 / nm. 2. ]) in contrast the young mice with an isolated fracture (33.6/nm. 2. [8.83/nm. 2. ]) fewer osteoclasts were present (p=0.009). Therefore, the severe blood loss further reduced the number of osteoclasts only in young animals (16.83/nm. 2. [6.07/nm. 2. ]) (p=0.004). In the in vivo μCT, after 2 weeks, a lower volume of bone, cortex and callus was found in old THFx animals (3.14 mm. 3. [0.64 mm. 3. ]); 1.01 mm. 3. [0.04 mm. 3. ]; 2.07 mm. 3. [0.57 mm. 3. ]) compared with the Fx animals (4.29 mm. 3. [0.74 mm. 3. ], p=0.008; 1.18 mm. 3. [0, 25 mm. 3. ], p=0.004; 3.02 mm. 3. [0.77 mm. 3. ], p=0.008) After 3 weeks, the ex vivo μCT scans also showed a reduced callus percentage in old THFx animals (61.18% [13.9 9%]), as well as a low number of trabeculae (1.81 mm. -1. [0.23 mm. -1. ]) compared to animals without blood loss (68.72% [15.71%], p = 0.030; 2.06mm. -1. [0.37mm. -1. ], p=0.041). In the biomechanical test, a reduced elasticity limit of the old THFx mice (7.75 N [3.33 N]) in contrast to the old Fx (10.24 N [3.32 N]) animals was shown (p=0.022). Conclusions. A severe blood loss has a higher negative effect on the healing, morphometry, and biomechanical properties of previously fractured femora in old compared to young individuals

Tourniquet is widely used in orthopedic surgery to reduce intraoperative bleeding and improve visualization. We evaluated the effect of tourniquet application on both peri- and postoperative cefuroxime concentrations in subcutaneous tissue, skeletal muscle, calcaneal cancellous bone, and plasma. The primary endpoint was the time for which the free drug concentration of cefuroxime was maintained above the clinical breakpoint minimal inhibitory concentration (T>MIC) forStaphylococcus aureus (4 µg/mL). Ten patients scheduled for hallux valgus or hallux rigidus surgery were included. Microdialysis catheters were placed for sampling of cefuroxime concentrations bilaterally in subcutaneous tissue, skeletal muscle, and calcaneal cancellous bone. A tourniquet was applied on the thigh of the leg scheduled for surgery. Cefuroxime (1.5 g) was administered intravenously as a bolus 15 minutes prior to tourniquet inflation, followed by a second dose 6 hours later. The mean tourniquet duration (range) was 65 (58; 77) minutes. Dialysates and venous blood samples were collected for 12 hours. For cefuroxime the T>MIC (4 μg/mL) ranged between 4.8–5.4 hours across compartments, with similar results for the tourniquet and non-tourniquet leg. Comparable T>MIC and penetration ratios were found for the first and second dosing intervals. We concluded that administration of cefuroxime (1.5 g) 15 minutes prior to tourniquet inflation is safe in order to achieve tissue concentrations above 4 µg/mL throughout surgery. A tourniquet application time of approximately 1 hour did not affect the cefuroxime tissue penetration in the following dosing interval

Tourniquet is widely used in extremity surgery. In order to prevent surgical site infection, correct timing of antimicrobial prophylaxis and tourniquet inflation is important. We aimed to evaluate the time for which the free drug concentration of cefuroxime is maintained above the minimal inhibitory concentration (T>MIC) in subcutaneous tissue and calcaneal cancellous bone during three clinically relevant tourniquet application scenarios. Twenty-four female pigs were included. Microdialysis catheters were placed for sampling of cefuroxime concentrations bilaterally in calcaneal cancellous bone and subcutaneous tissue, and a tourniquet cuff was applied on a randomly picked leg of each pig. Subsequently, the pigs were randomized into three groups to receive 1.5 g of cefuroxime by intravenous injection 15 min prior to tourniquet inflation (Group A), 45 min prior to tourniquet inflation (Group B), and at the tourniquet release (Group C). The tourniquet duration was 90 min in all groups. Dialysates and venous blood samples were collected eight-hours postcefuroxime administration. Cefuroxime concentrations were maintained above the clinical breakpoint MIC for Staphylococcus aureus (4 μg/mL) in calcaneal cancellous bone and subcutaneous tissue throughout the 90 min tourniquet duration in Group A and B. Cefuroxime administration at tourniquet release (Group C) resulted in concentrations above 4 μg/mL for a minimum of 3.5 hours in the tissues on the tourniquet side. There were no significant differences in the T>MIC (4 μg/mL) in subcutaneous tissue or calcaneal cancellous bone between the three groups. However, Group A tended toward shorter T>MIC in tourniquet calcaneal cancellous bone compared to Group C (p=0.08). We conclude that administration of cefuroxime (1.5 g) in the 15–45 min window prior to tourniquet inflation resulted in sufficient calcaneal cancellous bone and subcutaneous tissue concentrations throughout the 90 min tourniquet application. If the target is to maintain postoperative cefuroxime concentrations above relevant MIC values, our results suggest that a second dose of cefuroxime should be administered at tourniquet release

Post-operative regimes involving the use of intra-articular local anaesthetic infiltration may allow early mobilisation in patients undergoing total knee arthroplasty. Few studies have evaluated such regimes outside specialist arthroplasty units. We aimed to determine whether an enhanced recovery programme including the use of local anaesthetic administration could be adapted for use in a district general setting. Following introduction of this regime to our unit, 100 consecutive patients undergoing primary total knee arthroplasty were reviewed. 56 patients underwent a standard analgesic regime involving a general or spinal anaesthetic and oral analgesics post operatively (group1). 48 patients underwent the newly introduced regime, which included pre-operative counselling, peri-articular local anaesthetic infiltration at operation and intra-articular local anaesthetic top-up administration post-operatively for 24 hours (group 2). Length of stay, post-operative analgesic requirements, and range of knee motion post-operatively were compared. Median length of stay was less for patients in group 2 compared with those in group 1 (4 days compared to 5 days, p<0.05). Patients in group 2 required lower total doses of opiate analgesia post-operatively. 90% of patients in group 2 were ambulant on the first post operative day, compared with less than 25% of patients in group 1. Mean knee flexion on discharge was greater in patients in group 2 compared with those in group 1 (85 degrees compared with 75 degrees). No infective complications from intra-articular catheter placement were observed. However, technical difficulties were encountered during the introduction period, including loss of catheter placement, leakage of local anaesthetic and adaptation of nursing time for top-up anaesthetic administration. A rehabilitation regime involving local anaesthetic infiltration for total knee arthroplasty can successfully be adapted for use in a district general setting. Our results suggest if initial technical difficulties are overcome, this regime can provide effective postoperative analgesia, early mobilisation and reduced hospital stay

Patients undergoing total knee arthroplasty (TKA) experience significant post-operative pain. We report the results of a new comprehensive patient care plan to manage peri-operative pain, enable early mobilisation and reduce length of hospital stay in TKA. A prospective audit of 1081 patients undergoing primary TKA during 2008 and 2009 was completed. All patients followed a planned programme including pre-operative patient education, pre-emptive analgesia, spinal/epidural anaesthesia with propofol sedation, intra-articular soft tissue wound infiltration, post-operative high volume intermittent ropivacaine boluses with an intra-articular catheter and early mobilisation. The primary outcome measure was the day of discharge from hospital. Secondary outcomes were verbal rating pain scores on movement, time to first mobilisation, nausea and vomiting scores, urinary catheterisation for retention, need for rescue analgesia, maximum flexion at discharge and six weeks post-operatively, and Oxford score improvement. The median day of discharge to home was post-operative day four. Median pain score on mobilisation was three for first post-operative night, day one and day two. 35% of patients ambulated on the day of surgery and 95% of patients within 24 hours. 79% patients experienced no nausea or vomiting. Catheterisation rate was 6.9%. Rescue analgesia was required in 5% of cases. Median maximum flexion was 85° on discharge and 93° at six weeks post-operatively. Only 6.6% of patients had a reduction in maximum flexion (loss of more than 5°) at six weeks. Median Oxford score had improved from 42 pre-operatively to 27 at six weeks post-operatively. The infection rate was 0.7% and the DVT and PTE rates were 0.6% and 0.5% respectively. This multidisciplinary approach provides satisfactory post-operative analgesia allowing early safe ambulation and discharge from hospital. Anticipated problems did not arise, with early discharge not being detrimental to flexion achieved at six weeks and infection rates not increasing with the use of intra-articular catheters

Purpose. In patients with multiple trauma delayed fracture healing is often diagnosed, but the pathomechanisms are not well known yet. The purpose of the study is to evaluate the effect of a severe hemorrhagic shock on fracture healing in a murine model. Methods. 10 male C57BL/6N mice per group (Fx, TH, THFx, Sham) and point in time were used. The Fx-group received an osteotomy after implantation of a fixateur extern. The TH-group got a pressure controlled hemorrhagic shock with a mean arterial blood pressure of 35 mmHg over 90 minutes. Resuscitation with 4 times the shed blood volume of Ringer solution was performed. The THFx group got both. Sham-animals received the implantation of a catheter and a fixateur extern but no blood loss or osteotomy. After 1, 2, 3, 4 or 6 weeks the animals were sacrificed. For the biomechanics the bones were analyzed via X-ray, µCT and underwent a 3-point bending test. The nondecalcified histology based on slices of Technovit 9100. The signaling pathway was analyzed via RT. 2. Profiler™ PCR Array Mouse Osteoporosis, Western Blot and Quantikine ELISA for RankL and OPG. Statistical significance was set at p < 0.05. Comparisons between groups were performed using the Mann–Whitney U (Fx vs. THFx) or Kruskal-Wallis Test (other groups). Results. The experiment showed that after 1 week the bones of the Fx- and THFx-mice were macroscopically instable. After 2 weeks the Fx-group showed macroscopically a stable bridging whereas the bones of the THFx-group were partly not stable bridged. 3 weeks after surgery the bones of both groups were stable bridged. Analysis via µCT showed that trauma hemorrhage leads to decreased density of the bone and callus and also to increased share of callus per bone volume after 2 weeks. The 3-point-bending test showed that the maximum bending moment is decreased in the group THFx compared to Fx after 2 weeks. The studies of the histology showed after 2 weeks a decrease in bone and cartilage after trauma-hemorrhage by optical analysis of photographs of the slices. The analyses of the signaling pathway pointed to an involvement of the RankL/Opg and IL6 pathway. Conclusion. A hemorrhagic shock has a negative effect on fracture healing in terms of reduced density of the bone and callus, increased share of callus per bone volume, decreased maximum bending moment, reduced mineralization of the callus and leads to changes in the RankL/Opg and IL6 pathways

Summary Statement. The spinal cord showed marked sensibility to acute compression causing complete and irreversible injury. On the contrary, the spinal cord has more ability for adaptation to slow progressive compression mechanisms having the possibility of neural recovery after compression release. Introduction. The aim of this experimental study was to establish, by means of neurophysiologic monitoring, the degree of compression needed to cause neurologic injury to the spinal cord, and analyze whether these limits are different making fast or slow compression. Material and Methods. Spinal cord was exposed from T7 to T11 in 5 domestic pigs with a mean weight of 35 kg. The T8 and T9 spinal roots were also exposed. A pair of sticks, attached to a precise compression device, was set up to both sides of the spinal cord between T8 and T9 roots. Sequentially, the sticks were approximated 0.5 mm every 2 minutes causing progressive spinal cord compression. An acute compression of the spinal cord was also reproduced by a 2.5 mm displacement of the sticks. Cord to cord motor evoked potentials were obtained with two epidural catheters, stimulating proximal to T6 and recording below the compression level, distal to T10, for each sequential approach of the sticks. Results. The mean width of the dural sac was 7.1 mm. For progressive compression, increasing latency and decreasing amplitude of the evoked potentials were observed after a mean displacement of the sticks of 3.2 ± 0.9 mm, the evoked potential finally disappearing after a mean displacement of 4.6 ± 1.2 mm. The potential returned 16.8 ± 3.2 minutes after the compression was stopped in every case. The evoked potentials immediately disappeared after an acute compression 2.5 ± 0.3 mm, without any sign of recovering after 30 minutes. Conclusion. The proposed experimental model replicates the mechanism of a spinal cord injury caused by medially displaced screws into the spinal canal, causing therefore lateral compression to the spinal cord. The spinal cord showed marked sensibility to acute compression, which caused complete and irreversible injury. On the contrary, the spinal cord has more ability for adaptation to progressive and slow compression mechanisms. From a clinical point of view, it seems mandatory to avoid maneuvers of rapid mobilization or acute, even minimal, contusions of the thoracic cord

Spinal nerve roots often sustain compression injuries. We used a Wistar rat model of the cauda equina syndrome to investigate such injuries. Rapid transient compression of the cauda equina was produced using a balloon catheter. The results were assessed by daily neurological examination and somatosensory evoked potential (SEP) recording before surgery and ten weeks after decompression. Compression of the spinal nerves induced changes in the SEP which persisted for up to ten weeks after decompression, but it had no effect on the final neurological outcome. Our study shows the importance of early surgical decompression for cauda equina syndrome

Objectives

All-suture anchors are increasingly used in rotator cuff repair procedures. Potential benefits include decreased bone damage. However, there is limited published evidence for the relative strength of fixation for all-suture anchors compared with traditional anchors.

Aims

We aimed to evaluate the temperature around the nerve root during drilling of the lamina and to determine whether irrigation during drilling can reduce the chance of nerve root injury.