Lower Extremity Orthopedic Procedures Research Articles

Discussion: Incidence of Major Arterial Abnormality in Patients with Wound Dehiscence after Lower Extremity Orthopedic Procedures.

Discussion: Incidence of Major Arterial Abnormality in Patients with Wound Dehiscence after Lower Extremity Orthopedic Procedures.

Incidence of Major Arterial Abnormality in Patients with Wound Dehiscence after Lower Extremity Orthopedic Procedures.

Surgical dehiscence can occur after lower extremity orthopedic procedures. Underlying vascular aberrancy and localized ischemia contribute to chronic wound development requiring advanced techniques such as free tissue transfer. Localized vascular abnormality is an underrecognized contributing factor to such dehiscence. The authors reviewed their lower extremity free tissue transfer experience in this population to analyze the incidence of arterial abnormality and outcomes. The authors conducted a retrospective review of 64 lower extremity free tissue transfers performed for chronic wounds after orthopedic procedures from 2011 to 2018. The primary outcome was major arterial abnormality as identified on angiography. Secondary outcomes were flap success, limb salvage, and ambulation status. The median age was 58 years, and 44 were men (69 percent). Comorbidities included osteomyelitis (77 percent), diabetes (39 percent), and peripheral vascular disease (17 percent). The incidence of arterial abnormality on angiography was 47 percent. Defect location correlated with angiosome of arterial abnormality in 53 percent. The flap success rate was 92 percent. Limb salvage and ambulation rates were 89 and 89 percent, respectively, at an average follow-up of 17.6 months. Men demonstrated an increased rate of limb salvage (p = 0.026). Diabetes (p = 0.012), arterial abnormality (p = 0.044), and arterial flap complication (p = 0.010) correlated with amputation. The high incidence of arterial abnormality in this population highlights the importance of expedient multidisciplinary care, including vascular and plastic surgery. Diagnostic angiography is important for identifying major arterial abnormality and the need for free tissue transfer for definitive coverage.

Objective measures of gait and balance in healthy non-falling adults as a function of age

BackgroundNeurodegenerative diseases increase in incidence with age. Prior studies using differing populations and gait paradigms have reported various parameters changing with age, some of which correlate with falls and mortality. Here we use three different paradigms to evaluate gait and balance in healthy non-fallers. Research questionWhat objective gait and balance parameters are correlated with aging. MethodsHealthy subjects aged 21–79 years without histories of falls, lower extremity orthopedic procedures or chronic pain were included. Subjects walked on a 20 × 4 foot pressure sensor mat (Zeno Walkway, Protokinetics, Havertown, PA) under three different gait paradigms, (i) steady-state gait, (ii) dual-task while texting on a cellular phone and (iii) tandem gait. Data was collected and analyzed using PKMAS software (Protokinetics). Linear regression analysis, stepwise multivariate analysis, and grouped analysis of gait parameters was performed using SPSS 24 (IBM). ResultsSeventy-five subjects were enrolled. Grouped analysis and linear regression analysis showed differing significance in parameters tested. Step-wise multivariate analysis of all 31 parameters assessed from three different gait paradigms, showed weak but significant correlations in age with (i) stride-to-stride variability in (i) integrated-pressure of footsteps and (ii) stride-length during steady-state gait, (iii) mean stride-length on dual-task, and (iv) mean step-width on tandem gait (R2 = 0.382, t = 2.26, p = 0.026). SignificanceIn a population of healthy subjects without prior history of falls or medical illness that should affect gait, there were weak but significant age-related changes in objective measures of steady state gait and balance. Future prospective longitudinal data will help predict the relevance of this in relation to falls in the elderly.

Comparison of a single injection of morphine versus ketamine or neostigmine into the epidural space on postoperative analgesia and hormonal stress response after spinal anesthesia

Background In patients undergoing lower extremity orthopedic procedures who receive spinal anesthesia, an epidural injection of morphine, ketamine, or neostigmine has an effect on postoperative analgesia duration and hormonal stress response. Patients and methods We carried out a prospective, randomized study comparing the effects of addition of 0.6 mg morphine versus 50 mg ketamine versus 60 μg neostigmine into the epidural space in patients who received spinal anesthesia in terms of postoperative analgesia duration and hormonal stress response. Results There was marked prolongation in the postoperative analgesia (428 ± 257) and attenuation of the hormonal stress response in the morphine group compared with the other groups. Also, neostigmine led to prolongation of postoperative analgesia and attenuation of stress response but less than morphine (363 ± 119). Conclusion The preemptive morphine injection into the epidural space could attenuate hormonal stress response and led to prolongation in the postoperative analgesia period.

A survey of thrombosis prophylaxis use in patients undergoing arthroscopic surgery

The risk of venous thromboembolism (VTE) following minimally invasive joint surgery is poorly defined. Furthermore, few prospective studies have evaluated the effect of prophylaxis on the risk of VTE. The lack of data to guide therapy in such patients is concerning as many lower extremity orthopedic procedures are performed each year. The reported risk of VTE following knee arthroscopy varies from 0.6 to 17.9%[1–5], with the variation in rates attributable to study design and to diagnostic techniques.

Anesthetic care for the child with morquio syndrome: general versus regional anesthesia

Morquio syndrome is a subtype of the mucopolysaccharidoses (MPS IV) characterized by the intracellular accumulation of keratin sulfate. Anesthetic issues related to the primary disease process include infiltration of tissues with keratin sulfate leading to distortion of upper airway anatomy with difficult or impossible endotracheal intubation, infiltration of the cervical spine with odontoid hypoplasia placing these patients at risk for atlanto-axial subluxation and quadriparesis, as well as alterations in cardiorespiratory function. Two children with Morquio syndrome who required anesthetic care during lower extremity orthopedic procedures are presented. The anesthetic implications of Morquio syndrome are reviewed. General anesthesia was used in one case, whereas continuous spinal anesthesia, which was used in the second case, is reported for the first time in a child with mucopolysaccharidoses.

Pharmacodynamics and Pharmacokinetics of Epidural Ropivacaine in Humans

The purpose of this study was to characterize the pharmacodynamics and pharmacokinetics of three concentrations of the new long-acting amide local anesthetic, ropivacaine, given epidurally in 15 physical status ASA I or II patients for elective lower-extremity orthopedic procedures using a nonrandomized open-label design. Three groups of five patients each received either 0.5%, 0.75%, or 1.0% ropivacaine. Upper and lower levels of analgesia to pinprick were determined at frequent intervals until normal sensation had completely returned. Motor blockade was assessed by use of a modified Bromage scale after each determination of level of analgesia. Fifteen venous blood samples were collected over 12 h after ropivacaine injection. Pharmacokinetic parameters were derived using serum concentration-time data. No significant differences were found between the three groups in terms of onset or recovery of motor and sensory blockade. Median maximum thoracic levels of analgesia achieved were 8, 6, and 5 for the 0.5%, 0.75%, and 1.0% groups, respectively, and occurred at 29 +/- 11, 37 +/- 21, and 30 +/- 9 min. Respective times to two-segment regression were 2.8 +/- 1.0, 3.0 +/- 0.5, and 2.9 +/- 0.6 h. Total durations of sensory blockade were 5.4 +/- 0.7, 6.5 +/- 0.4, and 6.8 +/- 0.8 h, respectively. No statistically significant differences were noted between the three groups in terms of clearance (CL). The mean residence time (MRT) was significantly longer for the 0.5% group when compared with the 1% group. The peak concentration (Cmax) for the 0.5% group was found to be significantly lower than for either the 0.75% or 1% groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of pH-Adjusted Lidocaine Solutions for Epidural Anesthesia

One hundred forty-eight adult patients having epidural anesthesia for cesarean section, postpartum tubal ligation, lower extremity orthopedic procedures, or lithotriptic therapy were assigned to five groups. Group 1 patients were given a commercially prepared 1.5% lidocaine solution with 1:200,000 epinephrine plus 1 ml of normal saline per 10 ml of lidocaine; the solution pH was 4.6. Group 2 patients were given commercially prepared 1.5% lidocaine solution plus 1:200,000 epinephrine, with 1 mEq (1 ml) NaHCO3 per 10 ml of lidocaine; the solution pH was 7.15. Group 3 patients received the commercial solution of 1.5% lidocaine with 1:200,000 epinephrine; the solution pH was 4.55. Group 4 patients were given a mixture of 18 ml of 2% lidocaine with 30 ml of 1.5% lidocaine, both commercially packaged with 1:200,000 epinephrine, plus 1 mEq (1 ml) of NaHCO3 added per 10 ml of solution; the solution pH was 7.2. Group 5 patients received 1.5% plain lidocaine to which epinephrine was added to a final concentration of 1:200,000; the solution pH was 6.35. Times of onset of analgesia (time between the completion of the anesthetic injection and loss of scratch sensation at the right hip (L-2 dermatome)) and of surgical anesthesia (time between completion of injection and loss of discomfort following tetanic stimulation produced by a nerve stimulator applied to skin on the right hip) were significantly more rapid in the groups that received the pH-adjusted solutions (groups 4 and 2). Group 4 had the fastest mean onset time, 1.92 ± 0.17 min, followed by group 2, 3.31 ± 0.23 min. Onset times were progressively longer in group 5 at 4.27 ± 0.51 min, group 3 at 4.73 ± 0.37 min, and group 1 at 7.11 ± 0.82 min. The spread of sensory blockade was also significantly more rapid in the pH-adjusted groups 5, 10, and 15 min after epidural injection. In patients having cesarean sections in groups 1 and 2, plasma lidocaine levels in the maternal peripheral venous and in umbilical cord blood and Apgar scores were similar in both groups.

Comparison of pH-Adjusted Lidocaine Solutions for Epidural Anesthesia

One hundred forty-eight adult patients having epidural anesthesia for cesarean section, postpartum tubal ligation, lower extremity orthopedic procedures, or lithotriptic therapy were assigned to five groups. Group 1 patients were given a commercially prepared 1.5% lidocaine solution with 1:200,000 epinephrine plus 1 ml of normal saline per 10 ml of lidocaine; the solution pH was 4.6. Group 2 patients were given commercially prepared 1.5% lidocaine solution plus 1:200,000 epinephrine, with 1 mEq (1 ml) NaHCO3 per 10 ml of lidocaine; the solution pH was 7.15. Group 3 patients received the commercial solution of 1.5% lidocaine with 1:200,000 epinephrine; the solution pH was 4.55. Group 4 patients were given a mixture of 18 ml of 2% lidocaine with 30 ml of 1.5% lidocaine, both commercially packaged with 1:200,000 epinephrine, plus 1 mEq (1 ml) of NaHCO3 added per 10 ml of solution; the solution pH was 7.2. Group 5 patients received 1.5% plain lidocaine to which epinephrine was added to a final concentration of 1:200,000; the solution pH was 6.35. Times of onset of analgesia (time between the completion of the anesthetic injection and loss of scratch sensation at the right hip (L-2 dermatome] and of surgical anesthesia (time between completion of injection and loss of discomfort following tetanic stimulation produced by a nerve stimulator applied to skin on the right hip) were significantly more rapid in the groups that received the pH-adjusted solutions (groups 4 and 2). Group 4 had the fastest mean onset time, 1.92 +/- 0.17 min, followed by group 2, 3.31 +/- 0.23 min.(ABSTRACT TRUNCATED AT 250 WORDS)