Gershon Volpin

Minidose Bupivacaine–Fentanyl Spinal Anesthesia for Surgical Repair of Hip Fracture in the Aged

Background Spinal anesthesia for surgical repair of hip fracture in the elderly is associated with a high incidence of hypotension. The synergism between intrathecal opioids and local anesthetics may make it possible to achieve reliable spinal anesthesia with minimal hypotension using a minidose of local anesthetic. Methods Twenty patients aged ≥ 70 yr undergoing surgical repair of hip fracture were randomized into two groups of 10 patients each. Group A received a spinal anesthetic of bupivacaine 4 mg plus fentanyl 20 &mgr;g, and group B received 10 mg bupivacaine. Hypotension was defined as a systolic pressure of < 90 mmHg or a 25% decrease in mean arterial pressure from baseline. Hypotension was treated with intravenous ephedrine boluses 5–10 mg up to a maximum 50 mg, and thereafter by phenylephrine boluses of 100–200 &mgr;g. Results All patients had satisfactory anesthesia. One of 10 patients in group A required ephedrine, a single dose of 5 mg. Nine of 10 patients in group B required vasopressor support of blood pressure. Group B patients required an average of 35 mg ephedrine, and two patients required phenylephrine. The lowest recorded systolic, diastolic, and mean blood pressures as fractions of the baseline pressures were, respectively, 81%, 84%, and 85%versus 64%, 69%, and 64% for group A versus group B. Conclusions A “minidose” of 4 mg bupivacaine in combination with 20 &mgr;g fentanyl provides spinal anesthesia for surgical repair of hip fracture in the elderly. The minidose combination caused dramatically less hypotension than 10 mg bupivacaine and nearly eliminated the need for vasopressor support of blood pressure.

A comparison of minidose lidocaine-fentanyl and conventional-dose lidocaine spinal anesthesia.

The syndrome of transient neurologic symptoms (TNS) after spinal lidocaine has been presumed to be a manifestation of local anesthetic neurotoxicity. Although TNS is not associated with either lidocaine concentration or dose, its incidence has never been examined with very small doses of spinal lidocaine. One hundred ten adult ASA physical status I and II patients presenting for arthroscopic surgery of the knee were randomly assigned to receive spinal anesthesia with either 1% hypobaric lidocaine 50 mg (Group L50) or 1% hypobaric lidocaine 20 mg + 25 &mgr;g fentanyl (Group L20/F25). Hemodynamic data, block height and regression, and time to first micturition and discharge were recorded. Follow-up phone calls were made by a blinded researcher at 48–72 h using a standardized questionnaire. Both groups had a median peak cephalad block level of T10. Lidocaine 50 mg was associated with a greater decrease in systolic blood pressure and a greater need for ephedrine. Time until block regression to the S2 dermatome (80 vs 110 min) and outpatient time to void (130 vs 162 min) and discharge (145 vs 180 min) were faster in the L20/F25 group. Complaints of TNS were found in 32.7% of the patients in the L50 group and in 3.6% of the patients in the L20/F25 group. We conclude that spinal anesthesia with lidocaine 20 mg + fentanyl 25 &mgr;g provided adequate anesthesia with greater hemodynamic stability and faster recovery than spinal anesthesia with lidocaine 50 mg. The incidence of TNS after spinal lidocaine 20 mg + fentanyl 25 &mgr;g was significantly less than that after spinal lidocaine 50 mg. Implications The use of a small-dose lidocaine plus fentanyl combination for spinal anesthesia provides greater hemodynamic stability, faster recovery, and a significantly reduced incidence of transient neurologic symptoms than a conventional dose (50 mg) of spinal lidocaine.

Intraarticular fentanyl compared with morphine for pain relief following arthroscopic knee surgery.

PurposeTo compare the analgesia produced by comparable doses of intra-articular (IA) morphine and fentanyl.MethodsSixty-nine healthy patients undergoing arthroscopic surgery received a standardized general anesthetic of 4 mg· kg−1 thiopental and 2 μg· kg−1 fentanyl followed by 2 mg· kg−1 succinylcholine prior to tracheal intubation and controlled ventilation. Maintenance of anesthesia was achieved with N2O/O2 and isoflurane. At the conclusion of surgery intra-articular injection was: Group I (n=23) 50 μg fentanyl in 20 ml saline; Group II (n = 24) 3 mg morphine in 20 ml saline; Group III (n=22) 20 ml saline. Pain scores at rest using a visual analogue scale were recorded by a separate blinded observer at one, two, four, and eight hours postoperatively.ResultsPain scores at one, two, four, and eight hours were 36, 26.3, 20.9, and 12.8vs 35.8, 33.8, 28.8, and 21.9 vs 70.5, 57.7, 58.4, and 53.6 for the IA-fentanyl, IA-morphine, and control groups respectively. Pain scores were greater at all times for Group III. Pain scores for Groups I and II were similar at one hour, but thereafter were less (P < 0.001) for the IA-fentanyl group.ConclusionBetter postoperative analgesia was achieved with 50 μg intraarticular fentanyl than with 3 mg intraarticular morphine.ObjectifComparer l’analgésie produite par des doses comparables de morphine et de fentanyl intra-articulaires (IA).MéthodeSoixante-neuf patients en santé devant subir une intervention arthroscopique ont reçu une anesthésie générale standard avec 4 mg· kg−1 de thiopental et 2 μg· kg−1 de fentanyl suivis de 2 mg· kg−1 de succinylcholine avant l’intubation endotrachéale et la ventilation contrôlée. On a maintenu l’anesthésie avec N2O/O2 et de l’isoflurane. À la fin de l’opération, l’injection intra-articulaire comprenait: Groupe I (n=23), 50 μg de fentanyl dans 20 ml de solution salée; Groupe II (n=24) 3 mg de morphine dans 20 ml de solution salée; Groupe III (n=22) 20 ml de solution salée. Les scores de douleur ont été notés au repos au moyen d’une échelle visuelle analogue par un observateur impartial distinct à une, deux, quatre et huit heures après l’opération.RésultatsLes scores ont été à une, deux, quatre et huit heures de 36-26,3-20,9-12,8vs 35,8-33,8-28,8-21,9 vs 70,5-57,7-58,4-53,6 pour les patients qui ont reçu du fentanyl IA, de la morphine IA et la solution salée, respectivement. Les scores de douleur ont été plus grands, en tout temps, chez les patients du Groupe III. Les scores de douleur ont été similaires chez les patients des Groupes I et II à une heure, mais moindres par la suite (P < 0,001) pour les patients qui ont reçu du fentanyl IA.ConclusionUne analgésie plus efficace a été obtenue avec l’injection intra-articulaire de 50 μg de fentanyl plutôt que 3 mg de morphine.

Correction of combined angular and rotational deformities by the Ilizarov method.

Deformities of the lower extremities are often a combination of angular and rotational components. The rotational component of combined deformities may be difficult to measure using plain radiography. Based on the current study, the computed tomography rotational malalignment test was developed. Evaluation of lower extremity alignment was done on 56 patients. Rotational malalignment was diagnosed in 14 limbs of nine patients. In all patients, correction of angular and rotational deformities was done simultaneously using an Ilizarov external fixator. The frame included a standard angular distraction system and a derotation block interconnected via an additional empty ring. In all cases, successful correction of angular and rotational deformities was achieved. The pain was eliminated in all seven patients having preexisting chronic joint pain. There were no cases of deep infection or nonunion. This simple and reliable method allowed precise analysis of the deformity in the transverse plane. Preoperative frame construction incorporating the derotational module decreased the time of the operation and allowed one-stage correction of rotational and angular deformities without additional manipulations.

The surgical treatment of severe comminuted intraarticular fractures of the distal radius with the small AO external fixation device. A prospective three-and-one-half-year follow-up study.

Although fractures of the distal radius are very common, an optimal treatment has not been clearly delineated. This is a prospective study of 40 patients, mainly young and active adults, with comminuted and unstable intraarticular fractures of the distal radius. The end results of closed reduction and rigid fixation with the small AO external fixator includes 36 patients (90%) with excellent and good results. Roentgenograms of 33 of these patients showed accurate alignment of the healed fractures. Four patients (10%) had a fair functional result, with a partial restriction of the range of movement, although roentgenograms demonstrated good alignment of the healed fractures. The small AO external fixator is both a useful and convenient method for the reconstruction and treatment of comminuted intraarticular fractures of the distal radius.

Cytokine Levels as Potential Biomarkers for Predicting the Development of Posttraumatic Stress Symptoms in Casualties of Accidents

Background: Traumatic injuries are usually associated with increased secretion of pro-inflammatory cytokines, and are sometimes followed by the development of acute stress symptoms (ASS) and posttraumatic stress symptoms (PTSS). Aims: To measure serum pro- and anti-inflammatory cytokines in accident casualties and to associate it with ASS at hospitalization, and with PTSS 1 month later. Methods: Participants were 48 patients, aged 20–60, hospitalized following various orthopedic injuries including bone fractures, and 13 healthy volunteers matched for gender. At hospitalization (Time 1), 30 ml heparinized venous blood were drawn and cytokines levels in serum were assessed; participants filled out the Acute Stress Disorder Inventory (ASDI), COPE, and injury-related questionnaires. One month later (Time 2), 26 participants filled out the Posttraumatic Disorder Symptom Scale (PDS). Results: High serum levels of IL-6, IL-8, and TGF-β and low levels of serum IL-4 and IL-10 were found in injured patients as compared with controls. When controlling for age and severity of injury in the regression analysis, higher levels of IL-6 and IL-8 and lower TGF-β were predicted by higher ASS and higher use of and emotion-focused coping. Higher PTSS scores at Time 2 were predicted by higher levels of IL-8, lower levels of TGF-β, and higher ASS measured at Time 1. Conclusions: High levels of the pro-inflammatory cytokine IL-6 and IL-8 and lower levels of the regulatory cytokine TGF-β should be further assessed as a possible risk factor or a bio-marker of PTSS in accident casualties.

Vascularized Muscle Pedicle Flap for Osteonecrosis of the Femoral Head

Osteonecrosis is a devastating, locally progressive degenerative condition that mainly affects young adults. Osteonecrosis of the femoral head requires biological hip reconstruction. This article describes a technique that uses a vascularized muscle pedicle flap as a viable bone graft for treatment of this condition.

Possible association of Toll-like receptor 9 polymorphisms with cytokine levels and posttraumatic symptoms in individuals with various types of orthopaedic trauma: Early findings

BACKGROUND Although TLR9 polymorphisms may be associated with cytokine dysregulation, its role in regulation of cytokines due to bodily trauma or in relation to acute stress symptoms or posttraumatic stress symptoms (ASS/PTS) has not been evaluated. AIMS To assess serum cytokine levels and levels of ASS and PTS in relation to four common TLR9 single-nucleotide polymorphisms (SNPs) in individuals with various types of orthopaedic trauma. METHODS Forty-eight accident-injured individuals, aged 20-60 years were studied. Serum cytokine levels and TLR9 SNPS (1486T/C, 1237T/C, 1174G/A and 2848G/A) were assessed together with intensity of ASS and PTS symptoms. RESULTS Statistically significant higher serum levels of IL-12 and IL-1β (p<.05) were found in individuals heterozygous for TLR9-1237 (TC) than in individuals expressing the most common TLR9-1237 type (TT), while differences in levels of IL-6 were not significant. Also, marginally significant levels of IL-6 were found in individuals expressing the common TLR9-1174 (GG) compared with individuals homozygous (AA) or heterozygous (GA) for this SNP. They also had non-significant higher intensity of ASS symptoms. A trend of higher PTS levels in individuals expressing the most common type TLR9-1174 (GG) was found, contrary to homozygous (AA) and heterozygous individuals (GA). CONCLUSIONS The results of this pilot study suggest that accident-injured individuals with certain TLR9 polymorphisms express higher levels of pro-inflammatory cytokines (IL-1β, IL-6 and IL-12). The associations of TLR9 SNPSs with increased risk of ASS or PTS should be further studied in larger groups of such patients.

Ulnar nerve monitoring during percutaneous pinning of supracondylar fractures in children.

Background: Supracondylar fractures of the humerus in children are frequently managed by closed reduction and percutaneous pinning. Insertion of medial and lateral pins is more stable than lateral pinning alone, but carries an increased risk for ulnar nerve damage. This study describes the use of electrical stimulation concurrent with medial pin insertion as a monitoring technique for avoiding iatrogenic ulnar nerve injury. Methods: A retrospective review was conducted on 138 children, mean age 5.6 years (SD±2.5), who were admitted to the hospital between 2007 and 2010 with uncomplicated supracondylar fractures, Gartland type II and above, and intact neurovascular presentation. The location of the ulnar nerve was identified and marked preoperatively by observing twitch contractions in response to electrical stimulation. The medial pin served as an active electrode during pin insertion, and repeated stimulation throughout the insertion process ensured no contact with the response of the ulnar nerve. After pin insertion, ulnar nerve stimulation was used again to ensure nerve continuity viability. Results: All fractures were stabilized with 2 to 4 cross K-wires (size 1.6 mm), with number depending on stability of the fracture. The children were discharged home 2 days after fracture fixation, with no iatrogenic ulnar nerve injury observed in any of the children. The only postoperative complication involved 2 cases of anterior interosseus nerve neuropraxia, which resolved spontaneously after 4 to 6 months. Primary fracture healing was achieved without nonunions or delayed unions in all cases. Conclusions: Ulnar nerve stimulation before and during the percutaneous pinning of supracondylar fractures in children is a simple, economical, and easy-to-implement technique that can prevent iatrogenic ulnar nerve injury. Level of Evidence: Level IV.

Surgical Treatment of Displaced Calcaneal Fractures

Calcaneal fractures (2% of all fractures) are usually the result of high energy injuries, falls from a height and road traffic accidents [1]. These fractures are the most common tarsal fractures and 60–75% of them are displaced intra-articular fractures. Calcaneal fractures are more common in males (90%), mostly industrial workers, 41–45 years of age. Ten per cent have associated fractures of the spine and 25% have other extremity injuries. The economic impact is enormous since about 20% of the patients are totally incapacitated for 3–5 years [1–3]. Despite advances in imaging, surgical techniques and surgical devices the functional results of displaced intra-articular fractures are not optimal and the literature still reveals controversy surrounding classification and treatment [4]. The purpose of this review is to present the anatomical and radiological structure of the calcaneus and various clinical aspects and surgical modalities for these types of fractures.