Der Orthopäde
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Pain therapy after surgical procedures of the lower extremity is an important goal, whereas insufficient analgesia leads to an essential reduction of the patient's mobility and convalescence. If possible, regional anaesthetic and intrathecal procedures for pre-, intra- and postoperative analgesia should be used. Systemic analgesics should not be used preoperatively, whereas non-opioids and opioids are recommended postoperatively. ⋯ There is no scientific rationale as an argument for inserting drains. The surgical approach depends more on the individual patient's anatomical characteristics. Whereas the regional analgesic regimen is more effective than systemic therapy, sufficient tools for pain reduction during surgical procedures of the lower extremity are at the orthopaedic surgeon's disposal, too.
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A dorsal approach during spinal surgery offers the possibility to distribute drugs directly to the nerve root or epidurally. This can be done via a single intraoperative dose or by placing an epidural catheter. A safe and effective analgesia can thereby be achieved. ⋯ Here the local application of local anesthetics or opioids makes sense. In transthoracic approaches epidural analgesia is recommended by thoracic surgeons, but this is difficult to perform especially in children with deformities. Furthermore it is generally important not to compromise neuralgic controls by analgesic measures.
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Orthopaedic and traumatized patients often suffer from severe pain after surgery or trauma. Their early recovery also depends on an efficient acute pain relief based on a combination of systemic medication, local drug application and physical therapy. In 2007, new guidelines for the treatment of perioperative and traumatic pain were published. ⋯ It is helpful to establish an acute pain service for daily rounds and documentation. The individual patient should be informed about his specific acute pain therapy before the operation. Pain scores should be frequently documented by the patient.
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Surgery of the shoulder, elbow, and hand can cause considerable pain. According to data from randomized controlled trials, local or regional anesthesia is recommended for analgesia during and after surgery of the upper extremity. ⋯ For the elbow joint, a peripheral block is also recommended to allow for effective analgesia and physiotherapy postoperatively. In addition, cooling and physiotherapeutic techniques are beneficial in postoperative management.
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Review Comparative Study
[Patients with pre-existing chronic pain and/or psychological problems].
Existing pain chronification and psychological problems can affect the degree of perioperative pain and hence the postoperative outcome. Most elective surgery performed on the musculoskeletal system is indicated because of pain. To avoid perioperative complications it is therefore essential to identify patients with existing pain chronification before surgery is performed. ⋯ In line with what is known about the mechanisms of pain chronification, patients with existing chronification usually display additional psychological problems. These psychological factors ought to be established prior to surgery. A preliminary non-surgical treatment could potentially also lead to a reassessment of the indication for surgery.