Irina Grosu

Pain after knee arthroplasty: an unresolved issue

AbstractPurposenDespite the recent advances in the understanding of pain mechanisms and the introduction of new drugs and new techniques in the postoperative management, pain after total knee arthroplasty (TKA) is still an unresolved issue. It affects the quality of life and rehabilitation of an important percentage of patients undergoing TKA. The aim of this narrative review was to give an overview on pain mechanisms and multimodal pain management.MethodsA review of all peer-reviewed articles on pain after knee arthroplasty was performed by two reviewers. Recent articles on incisional pain mechanisms were included because of their importance in the understanding of postsurgical pain. Search was performed in Pubmed, Cochrane and Google Scholar data bases.ResultsPostsurgical pain mechanisms are based on both local and systemic inflammatory reactions. Peri-operative pain management starts with the anaesthetic technique and resides on a multimodal analgesia regimen. New concepts, drugs and techniques have shown their efficacy in reducing the severity of acute postoperative pain and the risk of developing chronic pain after TKA.ConclusionThis narrative review offers a clear overview of pain mechanism after knee arthroplasty and an understanding on how multimodal pain management can reduce the intensity and duration of pain after knee arthroplasty.Level of evidenceIV.

The use of patient-specific instruments does not reduce blood loss during minimally invasive total knee arthroplasty?

AbstractPurposeBlood loss can be substantial and will influence morbidity and mortality after total knee arthroplasty. This study evaluated whether patient-specific instruments (PSI) can reduce blood loss because the intramedullary canal is not opened during the procedure and whether hidden blood loss can be reduced by its use.MethodsSeventy-five patients operated with the Signature PSI technique were compared with a matched group operated with conventional instruments. Maximal drop in haemoglobin (Hb) and hematocrit (HTC) level were compared at day 2 and day 4. Transfusions were noted. Clinical outcomes like range of motion and knee society scores were studied as secondary outcomes.ResultsNo statistically significant difference for calculated blood loss, maximal drop in Hb or HTC and transfusions were found. No clinical differences in range of motion or knee society scores were observed.ConclusionsThe use of PSI-assisted total knee arthroplasty (TKA) did not result in less blood loss compared with conventional minimally invasive TKA with tourniquet. No reduction in hidden blood loss was observed either. According to this study, the argument of reduced transfusion cost should not be used in cost-effectiveness calculations of PSI-assisted TKA.Level of evidenceIII.n

Anesthetic management of a child with Ullrich myopathy

To the Editor: A 9-year-old boy was scheduled for surgery to correct bilateral fixed plantar flexion. Because muscular weakness had been observed early in childhood, a muscle biopsy had been performed (result: myopathy), but a skin biopsy finally established the diagnosis of Ullrich’s myopathy (UD), a congenital muscle dystrophy. Preoperative physical examination showed a child with weight of 24 kg and height of 131 cm. Cervical spinal mobility was slightly limited; micrognathism and prominent incisive teeth were present. Creatinine phosphokinase (CK) level was at the upper limit of normal values for our laboratory. Cardiac and pulmonary function tests were normal. The patient had already undergone one general anesthesia in the past (for the muscle biopsy) consisting of total intravenous anesthesia (TIVA) with alfentanil and propofol. After careful positioning, standard monitoring was applied. Peripheral venous was obtained while the patient breathed O2 and N2O (50–50 %) by mask. Induction of anesthesia was performed with sufentanil (0.1 lg/kg) and propofol (3 mg/kg), followed with manual ventilation with sevoflurane. Orotracheal intubation was performed at first attempt (Cormack–Lehane stage 3). Surgery lasted 2 h. A tourniquet was used for each site successively. Core body temperature and capnography remained normal; no significant increase in expired CO2 was noticed when the tourniquets were released. In this surgery, as in the previous one, no muscle relaxant was used. Postoperative analgesia consisted of IV ketorolac, acetaminophen, and piritramide in the pediatric acute care unit (PACU). The postoperative evolution was satisfactory. No clinical signs of rhabdomyolysis (e.g., dark urine) were observed. No significant elevation in the CK levels was observed. The CK increased from 407 U/l before the surgery to 440 U/l after the surgery; the upper normal value of our laboratory is 400 U/l. The clinical diagnosis of UD is based on general muscle weakness, contractures of multiple joints, hyperextensibility of distal joints, and other orthopedic and systemic signs [1, 2]. There is no evidence of cardiac dysfunction, but the diaphragm is often involved early. Tracheal intubation may be difficult because of the combination of micrognathism and contracture of the temporomandibular muscles. When planning anesthesia for a child with a muscle disease, one of the anesthesiologist’s concerns is to limit the risk of inducing a malignant hyperthermia (MH) crisis or rhabdomyolysis. In this case, the risk of MH was estimated to be not greater than in the general population because the familial history was negative and the gene mutations for UD are different and distant from the known mutations of the RYR1 and CACNL1A3 genes associated with MH [3–5]. In conclusion, this case, in addition to the other published cases, shows that halogenated agents can be used safely in children with UD as well as in other congenital muscle dystrophies. I. Grosu (&) D. Truong S. Teodorescu M. Mousny F. Veyckemans Service d’Anesthésiologie, Departments of Anesthesiology and Orthopedics, Cliniques Universitaires Saint Luc, 10 Avenue Hippocrate, 1200 Brussels, Belgium e-mail: irina.grosu@uclouvain.be

Pain After Knee Arthroplasty: An Ongoing Battle

Despite recent advances in the understanding of pain mechanisms and the introduction of new drugs and techniques in the postoperative management, pain after knee arthroplasty is still an ongoing battle. It affects the quality of life and rehabilitation of an important percentage of patients undergoing knee arthroplasty. Understanding the postsurgical pain mechanisms and applying the basic principles of multimodal pain management are essential when managing pain after knee arthroplasty. Postsurgical pain mechanisms are based on the local and systemic inflammatory reaction. The incidence of acute and persistent pain after knee arthroplasty has diminished in the last 20 years, but it is still an important issue. The perioperative pain management starts with the anaesthetic technique and resides on a multimodal regimen of analgesia. New concepts, drugs and techniques have shown their efficacy in reducing the severity of acute postoperative pain and the risk of developing chronic pain after knee arthroplasty.