The American journal of orthopedics
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Uncontrolled pain associated with total knee arthroplasty can have significant untoward effects on patient outcomes, leading to delayed recovery, inability to participate in rehabilitation, prolonged hospitalization, and increased use of health care resources. In this article, I review the methodologies and outcomes of several studies and protocols involving preemptive, perioperative, and postoperative use of various anesthetic and analgesic agents. Used together with minimally invasive techniques, appropriate pain control should result in significant improvements in patient outcomes.
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Autogenous iliac crest bone graft (ICBG) is the gold standard of materials for spinal fusion. We conducted a prospective observational study of posterior autogenous ICBG harvesting and used process measures to establish a normative database of bone harvesting for future comparative studies and analyses of bone graft substitutes. Between August 2000 and March 2002, we obtained posterior autogenous ICBG from 36 consecutive patients (29 men, 7 women). ⋯ With the emergence of bone graft substitutes, costs and benefits of autogenous ICBG harvesting will be scrutinized. This database establishes a prospective benchmark for additional EBL, harvest time, harvest volume, and SI joint violation for ICBG harvesting. To our knowledge at the time of manuscript preparation, this is the first report of routine use of postoperative computed tomography to determine incidence of SI joint violation after ICBG harvesting.
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Evaluation and management of patients who sustain blunt trauma with multiple injuries have changed significantly over the past 50 years. Initially, clinical research supported delayed definitive treatment of the orthopedic subset of injuries in these patients. With the advancement of splinting and fixation techniques, this view changed to one of "early total care." Current developments in classifying trauma patients at risk for deterioration (objective scoring scales) and understanding the posttraumatic immune response have allowed us to stratify patients' clinical severity and treat appropriately. The damage-control philosophy proposes early stabilization, resuscitation, and delayed definitive treatment for polytrauma patients with orthopedic injuries who are most at risk.
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Randomized Controlled Trial
Postoperative pain management for arthroscopic shoulder surgery: interscalene block versus patient-controlled infusion of 0.25% bupivicaine.
We compared an interscalene block with a patient-controlled regional anesthesia device (Pain Care 2000; Breg, Inc, Vista, Calif) for pain management after outpatient arthroscopic shoulder surgery (subacromial decompression as principal procedure). The 41 patients in this prospective study were randomized to receive either the block or the device. During the postoperative period, all patients in both groups received standardized oral medications and continuous cold therapy and used continuous passive motion machines. ⋯ Compared with patients using the block, patients using the device awoke significantly fewer times the first night after surgery (P = .023), were significantly more active during postoperative days 1 and 2 (Ps = .018, .042), and took significantly fewer pain medications on postoperative day 2 (P = .034). On all other measures, results were equivalent or were better with the device, though these findings were not statistically significant. Patient-controlled subacromial infusion of bupivicaine is an effective alternative to interscalene block for outpatient pain management after arthroscopic shoulder surgery.
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Although previously considered rare, ruptures of the pectoralis major muscle and tendon have become more common over the past 20 years with increasing participation in competitive sports and weight lifting. These injuries result from maximal eccentric contraction of the muscle with the arm held in an abducted, extended position. Most often, they occur near the tendon insertion. ⋯ Partial tears and neglected complete tears with near complete restoration muscle strength after rehabilitation may be treated nonoperatively, with good results. Excellent results can be obtained with early anatomic repair for complete ruptures, though good results have also been reported with delayed repair of complete injuries. Early diagnosis and, when appropriate, anatomic surgical repair are the factors critical to optimizing patient outcomes after pectoralis major rupture.