Abstract. Objective. To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Methods. This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59–82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2–4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results. The mean (range) duration of anaesthesia was 38.66 (20–60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130–210 and 75–145 mmHg, respectively (mean [range] drop, 74.13 [33–125] mmHg). Mean (range) propofol dose was 1.74 (1–3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20–50) min. The mean (range) postoperative recovery score (local scale, range 5–28 where lower values are superior) was 5.2 (5–8). The mean (range) length of stay was 8 (1–20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions. Our data demonstrate that rTSA under ISB-RA is safe, cost-effective and a potentially viable alternative for patients with multiple comorbidities. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours

Botulinum toxin A (BoNT-A) is a substance that requires repeated application due to its effectiveness being lost 12–16 weeks post application. Performing these intra-muscular injections under anesthesia reduces pain and distress during applications, ensuring effective and successful functional results. This study evaluates motor development of patients undergoing 3 or more repeated BoNT-A application in a tertiary pediatric hospital and the safety as well as effect of 3 different types of anesthesia. 75 children with cerebral palsy who underwent BoNT-A application at least three times consecutively with 6-month intervals and a total of 320 procedures admitted between January 2008 and January 2018 were retrospectively examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. To observe the improvement in motor development, those with 2-1-0 level decreases in GMFCS classes were grouped and compared in terms of birth time, birth weight, cerebral palsy type and first BoNT-A application age. The 3 types of anesthesia methods (sedation analgesia, larengeal mask anesthesia (LMA) and inhalation mask anesthesia) applied during the procedures were compared in terms of sedation, procedure, recovery and total operation room time. The mean age of the children for all procedures was 45.51 ± 22.40 months. As a result of procedures, significant motor development was observed in 60 (80%) patients (p <0,000∗). No significant difference was observed when the children with cerebral palsy whose GMFCS declined in the form of level 2, 1 and unchanged were compared in terms of first application age, birth weight and gestational age. It was found that 106 (33.1%) were applied sevoflurane with anesthesia mask, 103 (32.1%) were administered sevoflurane with laryngeal mask, and 111 (34.6%) were sedation-analgesia. Only 10 out of 320 procedures were seen to develop side effects (8 vomiting, 2 bronchospasm). In the patients who underwent sedation analgesia during the first 3 BoNT-A procedures, the duration of recovery and total operating room time was seen to be significantly shorter than the others, while there was no difference between the anesthesia methods in the 4th and subsequent procedures. Regardless of the type of anesthesia, the recovery and total operating room times of those having undergone 6 or more procedures were longer than those with less than 6 procedures (p <0.009, p <0.016, respectively). As conclusion, repeated BoNT-A applications in children with CP provides progress in motor steps, it can be applied safely and effectively under anesthesia. Sedation analgesia application provides easier recovery compared to general anesthesia with LMA and mask only in the first three applications. However, recovery time increases with 4 and more repeated applications as the number of applications increases

Summary. Timing for the application and use of fentanyl patches for pre-emptive analgesia and sedation is crucial to obtain good clinical outcomes. Placement and timing is important to maximise clinical effect and apparent levels of analgesia. Introduction. The use of sheep as preclinical models for the investigation of orthopaedic conditions is gaining momentum, the control of their pain is a significant ethical issue. The daily need for injecting non-steroidal anti-inflammatory drugs (NSAIDs) and/or the shorter acting opioids increases the demand for handling post-operatively which can increase animal distress and risk of human injury. NSAIDs can have a negative effect on bone healing, complicating results. Opioid analgesics have no impact on bone healing. Fentanyl patches have become another option for use in pain management. Pre-emptive analgesia helps reduce the demand on post-operative analgesic use. Fentanyl has the added benefit of producing mild sedation. This study evaluated the pharmacokinetics of fentanyl patches in sheep in an effort to maximise pre and post-surgical analgesia. Methods. Eight sheep were divided into 2 groups of 4. Both groups had a 100µg/kg/hr fentanyl patch (Durogesic – Janssen, Sydney, Australia) applied to the clipped and cleaned skin of the antebrachium and were held in place with a light bandage. (A dose rate range of 1- 1.6µg/kg/hr was achieved). Group 1 had a second patch applied after 72 hours and group 2 had a second patch applied after 24 hours. Blood samples were taken at 0, 3, 6, 12, 24, 36, 48 and 72 hours post patch application. The blood was immediately spun down and the serum drawn off and frozen. Serum levels for fentanyl were measured using commercial ELISA kits and read using a spectrophotometer. Animal behaviour throughout the study was observed and recorded by trained staff (CC, JR). Results. Six hours after the patch application, the sheep were relaxed and easily approachable. They stood calmly while blood was being drawn. This behaviour remained up to the 48 hour time point at which time cornering them in their pen became marginally more difficult, however they still stood calmly for the blood collection. By 72 hours, all sheep co-operation had dissipated. Peak blood levels of Fentanyl were reached by 12 hours post patch application. These levels were maintained with a relatively flat drug plateau for the prescribed 72 hours post application. No difference was found in the peak drug levels post application of the second patch between the two groups. There was no second higher peak in blood levels attained. Discussion. This study quantified the drug absorption and elimination curves of fentanyl using a controlled application method in an effort to better apply and manage post-surgical analgesia in sheep used for orthopaedic studies. The results indicate that the application of fentanyl for pre-emptive surgical analgesia can be applied for the full duration of 72 hours prior to the application of the second patch at the time of surgery. No benefit regarding analgesia appears to be gained from changing the first patch after 24 hours as peak serum levels are not affected. However for peak sedation the second patch can be applied anytime from 6 to 48 hours. This analgesic regime is beneficial to the animal as well as its handling and management

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature. We aimed to describe our experience of forefoot surgery under ankle block. Sixty-six consecutive forefoot procedures (59 patients) were carried out under ankle block. Patients were contacted post operatively and completed a standardised questionnaire including an incremental pain assessment ranging from 0-10 (0 no pain, 10 severe pain). Forty nine female and 10 male patients (age range 20-85y) were included. Procedures included 33 first metatarsal osteotomies, 15 cheilectomies, 3 first MTP joint replacements, 5 fusions, 4 excision of neuroma and 6 other procedures. 22 patients (33% of cases) reported discomfort during the block procedure (average pain score 1.5). 6 patients reported pain during their operation(s), average score 0.26. Average pain scores at 6, 12, 24 and 48 hours following surgery were 2.0, 3.2, 2.7 and 2.1 respectively. All patients were discharged home and walking on the same day. There were no readmissions. Each patient confirmed they would have surgery under regional block rather than general anaesthesia and would recommend this technique to family and friends. There are many advantages in being able to perform these relatively small procedures under regional anaesthesia. The anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intra-operative sedation, use of ankle tourniquet and same day discharge; it has very high patient acceptance and satisfaction

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

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature. We aimed to describe our experience of forefoot surgery under ankle block alone. 21 consecutive forefoot procedures (18 patients) were carried out under ankle block. The blocks were performed by the senior authors. A mixture of 10ml 2% Lidocaine with 10ml 0.5 % Bupivacaine was administered to the superficial peroneal, deep peroneal, sural and saphenous nerves. Ankle tourniquet was employed in all procedures. The patients were contacted post operatively and completed a standardised questionnaire including an incremented pain assessment ranging from 0-10 (0 no pain, 10 severe pain). 17 female and 1 male patients were contacted (age range 33-67y). Procedures included 13 first metatarsal osteotomies, 3 cheilectomies, 2 first MTP joint replacements, and 5 fusions. 14 patients requested a short acting sedative (midazolam). 5 patients (27 %) reported some discomfort during the block procedure (average pain score 1.2). No patients reported any pain during their operation(s). 4 patients (22%) required supplementation of the block. Average pain score at 6, 12, 24 and 48 hours following surgery were 0.66, 2.9, 2.4 and 1.3 respectively. All patients were discharged home and walking on the same day. None complained of nausea or required parenteral analgesia; there were no readmissions. Each patient confirmed they would have surgery under local block rather than general anaesthesia and would recommend this technique to family and friends. Forefoot surgery under ankle block alone is safe and effective. Anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intraoperative sedation, use of ankle tourniquet and same day discharge, it has very high patient acceptance and satisfaction

Introduction. Osteonecrosis of the femoral head (ONFH) is one of the most serious complications associated with corticosteroid therapy. In patients with ONFH, collapse of the femoral head often occurs and causes severe hip pain and impaired hip joint function. Despite the widely spread use of corticosteroids for treating various diseases and a known association between prevalence of ONFH and daily dose of corticosteroids, the pathomechanism for the development of ONFH has not been identified. Since hepatic cytochrome P4503A (CYP3A) is a predominant enzyme responsible for metabolizing corticosteroids and its activities varies more than 10-fold, low hepatic CYP3A activity leads to a remarkable increase of corticosteroid levels and its effect. We have previously reported that hepatic CYP3A levels are significantly lower in patients with corticosteroid-induced ONFH than that in control patients and patients with alcohol-related ONFH and that hepatic CYP3A activity inversely correlated with the incidence of osteonecrosis and extent of the necrotic area caused by the same dose of corticosteroids in a rabbit model, suggesting possible prevention of the corticosteroid-induced osteonecrosis by adjusting corticosteroid dose based on the level of individual hepatic CYP3A activity prior to corticosteroid therapy. To examine hepatic CYP3A activity, measuring clearance of administrated midazolam (MDZ) is a reliable method, as shown by the significant correlations between the clearance of midazolam and hepatic CYP3A levels measured by biopsy and the clearance of other CYP3A-specific substrates. However, the method is invasive and time consuming for measuring clearance of administrated MDZ, needing multiple blood samplings over half a day for each subject. The aim of this study was to develop the simple, safe and noninvasive methods for measuring the level of hepatic CYP3A activity, which is applicable to prevent the occurrence of corticosteroid-induced osteonecrosis prior to corticosteroid therapy. Methods. Thirty seven healthy male (n=20) and female (n=17), volunteers who had a mean age of 27 years received single oral administration of a small quantity of midazolam (50 mg/kg) and concentrations of total midazolam and its principal metabolite, 1-hydroxymidazolam (1-OH-midazolam), in each plasma at 15, 30, 45, 60, and 90 minutes and 2, 3, 4, 6, 9 and 12 hours post-drug administration were measured. Secondarily, the assessment of the Observer's Assessment of Alertness/Sedation (OAA/S) Scale was also used during the 12-hour post-administration period. Results. The best correlations between midazolam clearance and the ratio of 1- OH- midazolam/ midazolam plasma concentrations measured at each experimental time were observed at 4 hours (R2 = 0.83) post-dosing, and better correlations were found at 3 hours with a strong correlation (R2 = 0.81). Good correlations between midazolam clearance and OAA/S scale were found at 15 minutes (p = 0.04). Conclusion. A single midazolam plasma measurement taken at 4 hours post-oral administration may represent an accurate marker of CYP3A activity. This simple, safe and noninvasive method for measuring CYP3A activity could be used for patients prior to corticosteroid therapy, and the adjusting dose of corticosteroids, tailor-made medicine, depending on the CYP3A activity of the individual patient could avoid the occurrence of corticosteroid-induced osteonecrosis

Objectives

We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change.

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.

Rebound growth after hemiepiphysiodesis may be a normal event, but little is known about its causes, incidence or factors related to its intensity. The aim of this study was to evaluate rebound growth under controlled experimental conditions.

A total of 22 six-week-old rabbits underwent a medial proximal tibial hemiepiphysiodesis using a two-hole plate and screws. Temporal growth plate arrest was maintained for three weeks, and animals were killed at intervals ranging between three days and three weeks after removal of the device. The radiological angulation of the proximal tibia was studied at weekly intervals during and after hemiepiphysiodesis. A histological study of the retrieved proximal physis of the tibia was performed.

The mean angulation achieved at three weeks was 34.7° (standard deviation (sd) 3.4), and this remained unchanged for the study period of up to two weeks. By three weeks after removal of the implant the mean angulation had dropped to 28.2° (sd 1.8) (p < 0.001). Histologically, widening of the medial side was noted during the first two weeks. By three weeks this widening had substantially disappeared and the normal columnar structure was virtually re-established.

In our rabbit model, rebound was an event of variable incidence and intensity and, when present, did not appear immediately after restoration of growth, but took some time to appear.

Cite this article: Bone Joint J 2015;97-B:862–8.

We studied the effects of coating titanium implants with teicoplanin and clindamycin in 30 New Zealand White rabbits which were randomly assigned to three groups. The intramedullary canal of the left tibia of each rabbit was inoculated with 500 colony forming units of Staphylococcus aureus. Teicoplanin-coated implants were implanted into rabbits in group 1, clindamycin-coated implants into rabbits in group 2, and uncoated implants into those in group 3. All the rabbits were killed one week later. The implants were removed and cultured together with pieces of tibial bone and wound swabs. The rate of colonisation of the organisms in the three groups was compared.

Organisms were cultured from no rabbits in group 1, one in group 2 but from all in group 3. There was no significant difference between groups 1 and 2 (p = 1.000). There were significant differences between groups 1 and 3 and groups 2 and 3 (p < 0.001). Significant protection against bacterial colonisation and infection was found with teicoplanin- and clindamycin-coated implants in this experimental model.

We have previously shown that joint distraction and movement with a hinged external fixation device for 12 weeks was useful for repairing a large articular cartilage defect in a rabbit model. We have now investigated the results after six months and one year. The device was applied to 16 rabbits who underwent resection of the articular cartilage and subchondral bone from the entire tibial plateau. In group A (nine rabbits) the device was applied for six months. In group B (seven rabbits) it was in place for six months, after which it was removed and the animals were allowed to move freely for an additional six months. The cartilage remained sound in all rabbits. The areas of type II collagen-positive staining and repaired soft tissue were larger in group B than in group A. These findings provide evidence of long-term persistence of repaired cartilage with this technique and that weight-bearing has a positive effect on the quality of the cartilage.

We have developed an animal model to examine the formation of heterotopic ossification using standardised muscular damage and implantation of a beta-tricalcium phosphate block into a hip capsulotomy wound in Wistar rats. The aim was to investigate how cells originating from drilled femoral canals and damaged muscles influence the formation of heterotopic bone. The femoral canal was either drilled or left untouched and a tricalcium phosphate block, immersed either in saline or a rhBMP-2 solution, was implanted. These implants were removed at three and 21 days after the operation and examined histologically, histomorphometrically and immunohistochemically.

Bone formation was seen in all implants in rhBMP-2-immersed, whereas in those immersed in saline the process was minimal, irrespective of drilling of the femoral canals. Bone mineralisation was somewhat greater in the absence of drilling with a mean mineralised volume to mean total volume of 18.2% (sd 4.5) versus 12.7% (sd 2.9, p < 0.019), respectively.

Our findings suggest that osteoinductive signalling is an early event in the formation of ectopic bone. If applicable to man the results indicate that careful tissue handling is more important than the prevention of the dissemination of bone cells in order to avoid heterotopic ossification.

We used a canine intercalary bone defect model to determine the effects of recombinant human osteogenic protein 1 (rhOP-1) on allograft incorporation. The allograft was treated with an implant made up of rhOP-1 and type I collagen or with type I collagen alone.

Radiographic analysis showed an increased volume of periosteal callus in both test groups compared with the control group at weeks 4, 6, 8 and 10. Mechanical testing after 12 weeks revealed increased maximal torque and stiffness in the rhOP-1 treated groups compared with the control group.

These results indicate a benefit from the use of an rhOP-1 implant in the healing of bone allografts. The effect was independent of the position of the implant. There may be a beneficial clinical application for this treatment.