The American journal of orthopedics
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The current use of multimodal analgesia for the management of postoperative pain has resulted in reduced side effects and improved pain relief. Limitations of the technology associated with current pump- or catheter-based systems have prompted the development of continuous delivery systems and extended-duration techniques for pain relief. Among these are morphine sulfate sustained-release liposome injection (Morphine SR, DepoMorphine) and the patient-controlled transdermal system (PCTS, E-TRANS). ⋯ E-TRANS fentanyl PCTS is a transdermal system attached to the patient's arm or upper chest; a button on the device is controlled by the patient to deliver doses of fentanyl. In a study comparing fentanyl HCl PCTS with conventional IV-patient-controlled analgesia (PCA) morphine, PCTS was found to be as safe and effective as PCA for the treatment of postoperative pain. Novel delivery systems that are less invasive, that are compatible with anticoagulation regimens, and that provide continuous delivery, thus preventing analgesic gaps, will facilitate rehabilitation and recovery and ultimately improve patient outcomes.
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Unrelieved postoperative pain following arthroplasty has been shown to delay patients' recovery and discharge from the hospital. Undertreatment of acute pain may also result in greater use of healthcare resources and ultimately lead to poor outcomes. ⋯ A therapeutic combination of analgesics (eg, opioids, nonsteroidal anti-inflammatory drugs, and bupivicaine) can provide adequate pain relief; however, regional anesthesia is fraught with side effects. The use of multimodal analgesia reduces hospital stay, decreases medical complications, and increases patient satisfaction.
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Controlling postoperative pain following painful orthopedic procedures such as total knee arthroplasty is an ongoing challenge, as current pain management techniques often result in undermedication and/or complications. Traditional pain management strategies include opioid analgesics administered orally or via epidural catheter, patient-controlled analgesia (PCA), or intramuscular (IM) injection. ⋯ PCA has been shown to provide more effective analgesia than IM dosing, and PCA administration is preferred over IM dosing by both patients and nurses. Continuous infusion of bupivacaine via pain pump is also an effective modality for reducing postoperative pain and decreasing postoperative consumption of opioid analgesics.
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Postoperative pain management is critical for optimal care of orthopedic surgery patients. Opioids, administered intramuscularly, as epidurals, or IV as patient-controlled analgesia, are effective for severe pain. ⋯ Opioid-sparing NSAIDs, such as ketorolac, and COX-2-specific NSAIDS have use in pain management of hip, knee, and ACL procedures. An individualized regimen of appropriate analgesics, combined with nonpharmacologic treatments such as physical therapy or cryotherapy and patient education, can aid orthopedic surgery patients' recovery.
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Case Reports
Technique for percutaneous insertion of intramedullary nail for intertrochanteric hip fracture.
Intramedullary nailing has been proven to have biomechanical advantages over the use of a side plate and screw system. Further advantages may be gained with the use of a percutaneous technique, thereby minimizing blood loss, operative time, and overall morbidity. This article describes a technique for inserting an intramedullary nail percutaneously using a minimal-incision technique by utilizing fluoroscopy in cases of intertrochanteric hip fracture.