Evidence suggests that the alleviation of pain is enhancedby a strong patient-clinician relationship and attending to a patient’s social and mental health. There is a limited role for medication, opioids in particular.

Orthopaedic surgeons can use comprehensive biopsychosocial strategies to help people recover and can work with colleagues who have the appropriate expertise in order to maximize pain alleviation with optimal opioid stewardship.

Preparing patients for elective surgery and caring for them after unplanned injury or surgery can benefit from planned and practiced strategies based in communication science.

Cite this article: Bone Joint J 2020;102-B(9):1122–1127.

We present the 5.6- to 7.6-year results of our first 118 hydroxyapatite (HA)-coated total hip replacements in patients under 66 years of age. The titanium femoral component has proximal HA coating and was usually articulated with an HA-coated threaded cup. The HA coating of 50 microns thickness has a porosity of below 3%, 97% HA purity and 65% crystallinity. The survival rate at a mean of six years was 100% for the HA-coated stems and 99% for the HA-threaded cups. The average Harris hip score at one year was 96, and at three years and thereafter 98. There was a very low incidence of early pain after surgery. Serial radiographs showed rapid bony integration of implants with evidence of bone apposition on the coating within six months. By Engh's criteria, all the femoral components had confirmed bone ongrowth after three years. We found no deterioration of results with time, and consider that our clinical and radiological results show that HA coatings can provide early pain relief and durable implant fixation

We performed a double-blind, randomised controlled trial to assess the effectiveness of a continuous-infusion brachial plexus block with levobupivacaine compared with that of a standard single injection for the management of post-operative pain after surgery on the shoulder. Eight patients were randomised to receive a pre-operative brachial plexus block using 30 ml of levobupivacaine 0.5% with adrenaline 1:200 000 followed by insertion of a 20-gauge polyamide catheter. This was connected to a disposable elastometric pump, set immediately after surgery to administer a continuous flow of levobupivacaine 0.25% at a rate of 5 ml per hour. The other eight patients were randomised to receive only the initial injection of 30 ml. The study was double-blinded with the aid of sham catheters and clamped pumps. All patients were given regular paracetamol and were prescribed morphine through a patient-controlled analgesia pump. Motor and sensory block assessments, visual analogue scale pain scores and consumption of morphine were recorded after the operation and then at 6, 12 and 24 hours after administration of the block. Satisfactory motor and sensory block was achieved in all patients. The mean visual analogue scale pain score at 12 hours and consumption of morphine at 24 hours after injection were significantly lower (p < 0.05) in the continuous-infusion group. This group also took longer to request their first additional analgesia and reported a significantly higher overall level of satisfaction. Our study has shown that continuous interscalene infusion of levobupivacaine is an effective method of post-operative analgesia after major surgery of the shoulder

Aims

The aim of this study was to determine the general postoperative opioid consumption and rate of appropriate disposal of excess opioid prescriptions in patients undergoing primary unilateral total knee arthroplasty (TKA).

We have studied 180 patients (128 men and 52 women) who had undergone lumbar discectomy at a mean of 25.4 years (20 to 32) after operation. Pre-operatively, most patients (70 patients; 38.9%) had abnormal reflexes and/or muscle weakness in the leg (96 patients; 53.3%). At follow-up 42 patients (60%) with abnormal reflexes pre-operatively had fully recovered and 72 (75%) with pre-operative muscle impairment had normal muscle strength. When we looked at patient-reported outcomes, we found that the Short form-36 summary scores were similar to the aged-matched normative values. No disability or minimum disability on the Oswestry disability index was reported by 136 patients (75.6%), and 162 (90%) were satisfied with their operation. The most important predictors of patients’ self-reported positive outcome were male gender and higher educational level. No association was detected between muscle recovery and outcome. Most patients who had undergone lumbar discectomy had long-lasting neurological recovery. If the motor deficit persists after operation, patients can still expect a long-term satisfactory outcome, provided that they have relief from pain immediately after surgery

The aim of this study was to determine whether obesity affects pain, surgical and functional outcomes following lumbar spinal fusion for low back pain (LBP).

A systematic literature review and meta-analysis was made of those studies that compared the outcome of lumbar spinal fusion for LBP in obese and non-obese patients. A total of 17 studies were included in the meta-analysis. There was no difference in the pain and functional outcomes. Lumbar spinal fusion in the obese patient resulted in a statistically significantly greater intra-operative blood loss (weighted mean difference: 54.04 ml; 95% confidence interval (CI) 15.08 to 93.00; n = 112; p = 0.007) more complications (odds ratio: 1.91; 95% CI 1.68 to 2.18; n = 43858; p < 0.001) and longer duration of surgery (25.75 mins; 95% CI 15.61 to 35.90; n = 258; p < 0.001). Obese patients have greater intra-operative blood loss, more complications and longer duration of surgery but pain and functional outcome are similar to non-obese patients. Based on these results, obesity is not a contraindication to lumbar spinal fusion.

Cite this article: Bone Joint J 2015;97-B:1395–1404.

Hip replacement is a very successful operation and the outcome is usually excellent. There are recognised complications that seem increasingly to give rise to litigation. This paper briefly examines some common scenarios where litigation may be pursued against hip surgeons. With appropriate record keeping, consenting and surgical care, the claim can be successfully defended if not avoided. We hope this short summary will help to highlight some common pitfalls. There is extensive literature available for detailed study.

We investigated the incidence of anomalies in the vertebral arteries and Circle of Willis with three-dimensional CT angiography in 55 consecutive patients who had undergone an instrumented posterior fusion of the cervical spine.

We recorded any peri-operative and post-operative complications. The frequency of congenital anomalies was 30.9%, abnormal vertebral artery blood flow was 58.2% and vertebral artery dominance 40%.

The posterior communicating artery was occluded on one side in 41.8% of patients and bilaterally in 38.2%. Variations in the vertebral arteries and Circle of Willis were not significantly related to the presence or absence of posterior communicating arteries. Importantly, 18.2% of patients showed characteristic variations in the Circle of Willis with unilateral vertebral artery stenosis or a dominant vertebral artery, indicating that injury may cause lethal complications. One patient had post-operative cerebellar symptoms due to intra-operative injury of the vertebral artery, and one underwent a different surgical procedure because of insufficient collateral circulation.

Pre-operative assessment of the vertebral arteries and Circle of Willis is essential if a posterior spinal fusion with instrumentation is to be carried out safely.

Cite this article: Bone Joint J 2014;96-B:535–40.

The April 2013 Knee Roundup³⁶⁰ looks at: graft tension and outcome; chondrocytes at the midterm; pre-operative deformity and failure; the designer effect; whether chondroitin sulphate really does work; whether ACL reconstruction is really required; analgesia after TKR; and degenerative meniscus.

The April 2012 Spine Roundup³⁶⁰ looks at yoga for lower back pain, spinal tuberculosis, complications of spinal surgery, fusing the subaxial cervical spine, minimally invasive surgery and osteoporotic vertebral fractures, spinal surgery in the over 65s, and pain relief after spinal surgery

The purpose of this study was to establish whether exploration and neurolysis is an effective method of treating neuropathic pain in patients with a sciatic nerve palsy after total hip replacement (THR). A total of 56 patients who had undergone this surgery at our hospital between September 1999 and September 2010 were retrospectively identified. There were 42 women and 14 men with a mean age at exploration of 61.2 years (28 to 80). The sciatic nerve palsy had been sustained by 46 of the patients during a primary THR, five during a revision THR and five patients during hip resurfacing. The mean pre-operative visual analogue scale (VAS) pain score was 7.59 (2 to 10), the mean post-operative VAS was 3.77 (0 to 10), with a resulting mean improvement of 3.82 (0 to 10). The pre- and post-neurolysis VAS scores were significantly different (p < 0.001). Based on the findings of our study, we recommend this form of surgery over conservative management in patients with neuropathic pain associated with a sciatic nerve palsy after THR.

Cite this article: Bone Joint J 2013;95-B:20–2.

Pain, swelling and inflammation are expected during the recovery from total knee arthroplasty (TKA) surgery. The severity of these factors and how a patient copes with them may determine the ultimate outcome of a TKA. Cryotherapy and compression are frequently used modalities to mitigate these commonly experienced sequelae. However, their effect on range of motion, functional testing, and narcotic consumption has not been well-studied.

A prospective, multi-center, randomised trial was conducted to evaluate the effect of a cryopneumatic device on post-operative TKA recovery. Patients were randomised to treatment with a cryopneumatic device or ice with static compression. A total of 280 patients were enrolled at 11 international sites. Both treatments were initiated within three hours post-operation and used at least four times per day for two weeks. The cryopneumatic device was titrated for cooling and pressure by the patient to their comfort level.

Patients were evaluated by physical therapists blinded to the treatment arm. Range of motion (ROM), knee girth, six minute walk test (6MWT) and timed up and go test (TUG) were measured pre-operatively, two- and six-weeks post-operatively. A visual analog pain score and narcotic consumption was also measured post-operatively.

At two weeks post-operatively, both the treatment and control groups had diminished ROM and function compared to pre-operatively. Both groups had increased knee girth compared to pre- operatively. There was no significant difference in ROM, 6MWT, TUG, or knee girth between the 2 groups. We did find a significantly lower amount of narcotic consumption (509 mg morphine equivalents) in the treatment group compared with the control group (680 mg morphine equivalents) at up to two weeks postop, when the cryopneumatic device was being used (p < 0.05). Between two and six weeks, there was no difference in the total amount of narcotics consumed between the two groups. At six weeks, there was a trend toward a greater distance walked in the 6MWT in the treatment group (29.4 meters versus 7.9 meters, p = 0.13). There was a significant difference in the satisfaction scores of patients with their cooling regimen, with greater satisfaction in the treatment group (p < 0.0001). There was no difference in ROM, TUG, VAS, or knee girth at six weeks. There was no difference in adverse events or compliance between the two groups.

A cryopneumatic device used after TKA appeared to decrease the need for narcotic medication from hospital discharge to 2 weeks post-operatively. There was also a trend toward a greater distance walked in the 6MWT. Patient satisfaction with the cryopneumatic cooling regimen was significantly higher than with the control treatment.

In a randomised trial involving 598 patients with 600 trochanteric fractures of the hip, the fractures were treated with either a sliding hip screw (n = 300) or a Targon PF intramedullary nail (n = 300). The mean age of the patients was 82 years (26 to 104). All surviving patients were reviewed at one year with functional outcome assessed by a research nurse blinded to the treatment used. The intramedullary nail was found to have a slightly increased mean operative time (46 minutes (sd 12.3) versus 49 minutes (sd 12.7), p < 0.001) and an increased mean radiological screening time (0.3 minutes (sd 0.2) versus 0.5 minutes (sd 0.3), p <  0.001). Operative difficulties were more common with the intramedullary nail. There was no statistically significant difference between implants for wound healing complications (p = 1), or need for post-operative blood transfusion (p = 1), and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine versus three cases, p = 0.14). The extent of shortening, loss of hip flexion, mortality and degree of residual pain were similar in both groups. The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at one year from injury).

In summary, both implants produced comparable results but there was a tendency to better return of mobility for those treated with the intramedullary nail.

We undertook a prospective pilot study to determine whether arthroscopic surgery through the central compartment of the hip was effective in the management of a snapping iliopsoas tendon. Seven patients were assessed pre-operatively and at three, six, 12 and 24 months after operation. This included the assessment of pain on a visual analogue scale (VAS) and function using the modified Harris hip score.

All the patients had resolution of snapping post-operatively and this persisted at follow-up at two years. The mean VAS score for pain fell from 7.7 (6 to 10) pre-operatively to 4.3 (0 to 10) by three months (p = 0.051), and to 3.6 (1 to 8) (p = 0.015), 2.4 (0 to 8) (p = 0.011) and 2.4 (0 to 8) (p = 0.011) by six, 12 and 24 months, respectively. The mean modified Harris hip score increased from 56.1 (13.2 to 84.7) pre-operatively to 88.4 (57.2 to 100) at one year (p = 0.018) and to 87.9 (49.5 to 100) at two years (p = 0.02). There were no complications and no weakness occurred in the musculature around the hip.

Our findings suggest that this treatment is effective and would support the undertaking of a larger study comparing this procedure with other methods of treatment.

In a study on ten fresh human cadavers we examined the change in the height of the intervertebral disc space, the angle of lordosis and the geometry of the facet joints after insertion of intervertebral total disc replacements. SB III Charité prostheses were inserted at L3-4, L4-5, and L5-S1. The changes studied were measured using computer navigation sofware applied to CT scans before and after instrumentation.

After disc replacement the mean lumbar disc height was doubled (p < 0.001). The mean angle of lordosis and the facet joint space increased by a statistically significant extent (p < 0.005 and p = 0.006, respectively). By contrast, the mean facet joint overlap was significantly reduced (p < 0.001). Our study indicates that the increase in the intervertebral disc height after disc replacement changes the geometry at the facet joints. This may have clinical relevance.

We describe a new method of stabilising a painful unstable sternoclavicular joint using the sternocleidomastoid tendon and passing it through the medial clavicle and onto the manubrium sternum. This method is simple, reproducible and avoids the potential risks of reefing the joint to the first rib. The technique was used in seven cases of sternoclavicular joint instability in six patients who were reviewed at a mean of 39.7 months (15 to 63). Instability was markedly reduced or eliminated in all cases, but in one there was occasional persistant subluxation. There were minor scar complications after two procedures and one patient had transient ulnar neuritis.

This procedure provides satisfactory results in the medium term.

This study compared the demographic, clinical and patient-reported outcomes after total hip replacement (THR) and Birmingham Hip Resurfacing (BHR) carried out by a single surgeon. Patients completed a questionnaire that included the WOMAC, SF-36 scores and comorbid medical conditions. Data were collected before operation and one year after. The outcome scores were adjusted for age, gender, comorbid conditions and, at one year, for the pre-operative scores. There were 214 patients with a THR and 132 with a BHR. Patients with a BHR were significantly younger (49 vs 67 years, p < 0.0001), more likely to be male (68% vs 42% of THR, p < 0.0001) and had fewer comorbid conditions (1.3 vs 2.0, p < 0.0001). Before operation there was no difference in WOMAC and SF-36 scores, except for function, in which patients awaiting THR were worse than those awaiting a BHR.

At one year patients with a BHR reported significantly better WOMAC pain scores (p = 0.04) and in all SF-36 domains (p < 0.05). Patients undergoing BHR report a significantly greater improvement in general health compared with those with a THR.

We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were randomised after stabilisation of the fracture into two equal groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device. All other aspects of their rehabilitation were the same. The treatment was continued for ten days after operation.

Outcome measurements included the use of a visual analogue scale for pain, the brief pain inventory and Ketorolac for post-operative control of pain, and an overall assessment of outcome by the surgeon. There were significantly better results for the patients receiving treatment by active electrical stimulation (repeated measures analysis of variance, p < 0.001). The findings of this pilot trial justify a larger study to determine if these results are more generally applicable.