No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The efficacy of local anaesthetic for pain after iliac bone harvesting: A randomised controlled trial
Abstract
Autogenous bone grafting is commonly used in reconstructive surgery but postoperative pain from the donor site can be severe, delaying early mobilisation and preventing discharge from hospital.
An RCT of levobupivacaine infusion (16.25mg/h for 24h) of iliac crest wounds versus placebo. Postoperative pain was recorded immediately on returning to the ward, then at 1, 2, 3, 4, 5, 6h, morning and evening on subsequent days until discharge, and at the 7-day clinic appointment. Mobility was recorded twice daily and at 7days.
Of 46 evaluable patients, 25 were randomised to levobupivacaine and 21 to placebo. Mean pain scores for (i) average pain from initial assessment to 6h; (ii) 1day in the morning; (iii) 1day in the evening; (iv) at 2days; and (v) follow-up were all statistically significant in favour of lower pain scores in the levobupivicaine group (p-values all <0.01). Comparison between the study groups for mobility found 6 patients unable to get out of bed in the placebo group and none in the local anaesthetic group at the initial assessment (Fisher's exact test p-value=0.005), and 2 patients at 24h. Patients in the local anaesthetic group were always more mobile and this was statistically significant even at 7days for gait disturbance, limp, deviation of gait and unequalness of stride. There were no complications relating to the infusion system.
Local anaesthetic significantly reduced postoperative pain and improved mobility. We recommend that surgeons use a local anaesthetic infusion to improve the postoperative experience for their patients undergoing iliac crest grafting.
... To minimize postoperative donor site pain, preemptive analgesia strategies have been employed including intravenous analgesics, intraoperative local anesthetic sponges, nerve blocks, and local anesthetic infusion pumps (Wilkes and Thomas, 1994;Hahn et al., 1996;Hoard et al., 1998;Blumenthal et al., 2005;Singh et al., 2005;Singh et al., 2007;Coulthard et al., 2008;Dashow et al., 2009;Ouaki et al., 2009;Isyanov and Suresh, 2009;Meara et al., 2011;Gamli et al., 2012;Visoiu, 2014;Muzaffar et al., 2016). Intraoperative use of bupivacaine at the iliac crest donor site has been shown to delay the onset of pain, decrease postoperative opioid use, and lead to earlier ambulation (Hoard et al., 1998;Dashow et al., 2009;Gamli et al., 2012). ...
... Secondary ABG with iliac crest bone is standard in many comprehensive cleft care protocols (Paterson et al., 2016), despite the fact that donor site pain remains a significant limitation (Rawashdeh, 2008;Meara et al., 2011;Myeroff and Archdeacon, 2011). Attempts to more effectively manage donor site pain have often been met with disappointing results (Wilkes and Thomas, 1994;Hahn et al., 1996;Morrison and Jacobs, 2003;Blumenthal et al., 2005;Singh et al., 2005;Morgan et al., 2006;Baig et al., 2006;Singh et al., 2007;Charous, 2008;Coulthard et al., 2008;Elder et al., 2008;Ouaki et al., 2009;Yoost et al., 2009;Meara et al., 2011;Visoiu, 2014;Muzaffar et al., 2016). Furthermore, alternatives to autologous bone have been explored to alleviate donor site morbidity, such as allograft and Bone Morphogentic Protein-2 (BMP-2) (Francis et al., 2013;Sivak et al., 2014). ...
... Prior reports have demonstrated indwelling pain catheters reduce postoperative opiate use and pain scores (Wilkes and Thomas, 1994;Hahn et al., 1996 Singh et al., 2007;Charous, 2008;Coulthard et al., 2008;Elder et al., 2008;Yoost et al., 2009;Meara et al., 2011;Hidas et al., 2013;Pontarelli et al., 2013;Visoiu, 2014). Similarly, this study found that our minimally invasive ABG protocol including the use of an indwelling ropivacaine infusion catheter demonstrated a statistically significant decrease in maximum pain score compared to our previous protocols. ...
Objective:
To evaluate postoperative pain, hospital length of stay (LOS), and associated costs of multiple perioperative analgesic strategies following alveolar bone grafting (ABG).
Design:
Retrospective comparative cohort study.
Setting:
Tertiary care pediatric hospital.
Patients/participants:
Iliac crest bone graft (ICBG) harvest techniques: "Open Harvest" (n = 22), "Trephine Only" (n = 14), or "Trephine + Pain Pump" (n = 25).
Intervention:
The "Open Harvest" group underwent open ICBG harvest with 3-walled osteotomies. For the other 2 treatment groups, a trephine drill was used to harvest iliac crest bone with a ropivacaine infusion pump into the hip donor site ("Trephine + Pain Pump") or without ("Trephine Only"). Patients who underwent ABG with only cadaveric allograft were analyzed as a comparison group ("No Harvest").
Main outcomes measures:
Outcomes were planned prior to data collection: maximum pain score, hospital LOS, and associated health care costs.
Results:
Maximum pain scores were significantly higher in the "Open Harvest" group (7.3/10) compared to "Trephine + Pain Pump" (1.8/10; P < .0001) and "No Harvest" groups (2.8/10; P < .01). Hospital LOS decreased from 2.4 days ("Open Harvest") to 0.5 days (Trephine + Pain Pump"; P < .0001). Twelve (48%) patients from "Trephine + Pain Pump" were discharged on the day of surgery. The "Trephine + Pain Pump" saved an estimated 7265 for a bilateral ABG compared to "Open Harvest."
Conclusions:
The combined use of the trephine ICBG technique and ropivacaine infusion catheter effectively decreased pain, shortened hospital stay, and improved cost saving compared to patients who have undergone other methods of ICBG.
... 4,[11][12][13] Multiple methods have been described to control donor site pain in patients receiving ABG including opioids, nonsteroidal anti-inflammatory drugs, local anesthetic injections or nerve blocks, [14][15][16] anesthetic sponges, 15,17 and placement of continuous-infusion pain pumps. 8,12,13,[18][19][20][21][22][23] The concept of "fast track surgery" has prompted the creation of Enhanced Recovery After Surgery (ERAS) protocols. Enhanced Recovery After Surgery protocols are evidence based, multidisciplinary, multimodal perioperative pathways designed to improve patient safety and surgical outcomes with the goal of faster recovery and decreased hospitalization. ...
... In an attempt to improve postoperative pain control and hasten recovery times for same day discharge, many methods to control donor site pain have been described. 8,[12][13][14][15][16][17][18][19][20][21][22][23] Local anesthetic agents administered intermittently or continuously through indwelling pain pumps have revolutionized postoperative care for patients receiving ICBG. 8,12,16,18 In adults, the use of bupivacaine pain pumps after ICBG is shown to improve pain scores and decrease narcotic usage. ...
Introduction:
Secondary alveolar bone grafting (ABG) is a common procedure performed at cleft care centers used to fill the alveolar cleft. The advent of techniques such as minimally invasive trephine drill harvest and placement of continuous-infusion pain pumps at the donor site has made outpatient ABG an increasingly feasible and cost-effective procedure. However, enhanced recovery after surgery protocols to maximize pain control and recovery times for this patient population have not been well established.
Methods:
A retrospective single-institution review was conducted of pediatric patients with cleft palate who underwent iliac crest bone graft ABG at a large urban academic children's hospital from 2017 to 2022. Patient age, alveolar cleft repair laterality, pain scores, surgery duration, hospital LOS, readmissions, and re-operations within 30 days were examined.
Results:
Fifty-four patients met our inclusion criteria. Fifty patients (92.6%) received a pain pump during the operation. The median duration of surgery and LOS in the post-anesthesia care unit were 1.28 and 1.75 hours, respectively. Fifty-two patients (96.3%) were discharged on the same day as their surgery whereas 2 patients (3.7%) stayed in the hospital overnight. The median pain score at the time of discharge was 0 (interquartile range 0, 0). There were 6 (11.1%) minor complications including 5 pain pump malfunctions and 1 recipient site wound breakdown. There was 1 readmission (1.9%) for development of a surgical site infection at the hip and no re-operations within 30 days of surgery.
Conclusion:
The described outpatient ABG protocol demonstrates effective postoperative pain control, short hospital LOS, and few complications requiring hospital readmission or reoperation.
... The increased bioavailability of these liposomal compounds was achieved through polyethilenglycol grafts. The liposomes functionalized with this technique [25,48] have significant properties for the interaction with proteins and human cells, and have an important impact on the capacity of controlled release of local anesthetic [48,50,51]. Ilfeld et al., have carried out a femoral block in 14 healthy volunteers using liposomal bupivacaine in different doses (EXPAREL, Pacira Pharmaceuticals, Inc., San Diego, CA, USA) obtaining a variable sensitive blockade and a motor blockade that lasted for over 24 h, for the maximal used dose [52]. ...
... The levobupivacaine-maltozyl-β-cyclodextrine has decreased neurotoxicity of anesthetic agents after spinal anesthesia. There are numerous studies on the combination of anesthetic agents as basic substances or as salts in concentrations of 0.02% with α-ciclodextrine, β-ciclodextrine sau γ-ciclodextrine [33, 50,51]. Therefore, numerous systems have been obtained, capable of controlled and gradual release of the local anesthetic-gels, oils, suppositories, or patches. ...
With time, medical and pharmaceutical research has advanced significantly. However, one of the major issues is how to administer the active substance. Among these, it counts over-or under-dosage of the active substance, low response to treatment, or increased clinical risk of the patient. An innovative method able to avoid these obstacles is represented by controlled release systems for active substances. The interest for these systems came with allowing encapsulation in the antibiotic release matrices, local anesthetics, protein or other substances. Moreover, a number of such vehicles are now available to release controlled substances used predominantly in the anesthesia and intensive care unit.
... The increased bioavailability of these liposomal compounds was achieved through polyethilenglycol grafts. The liposomes functionalized with this technique [25,48] have significant properties for the interaction with proteins and human cells, and have an important impact on the capacity of controlled release of local anesthetic [48,50,51]. Ilfeld et al., have carried out a femoral block in 14 healthy volunteers using liposomal bupivacaine in different doses (EXPAREL, Pacira Pharmaceuticals, Inc., San Diego, CA, USA) obtaining a variable sensitive blockade and a motor blockade that lasted for over 24 h, for the maximal used dose [52]. ...
... The levobupivacaine-maltozyl-β-cyclodextrine has decreased neurotoxicity of anesthetic agents after spinal anesthesia. There are numerous studies on the combination of anesthetic agents as basic substances or as salts in concentrations of 0.02% with α-ciclodextrine, β-ciclodextrine sau γ-ciclodextrine [33,50,51]. Therefore, numerous systems have been obtained, capable of controlled and gradual release of the local anesthetic-gels, oils, suppositories, or patches. ...
With time, medical and pharmaceutical research has advanced significantly. However, one of the major issues is how to administer the active substance. Among these, it counts over- or under-dosage of the active substance, low response to treatment, or increased clinical risk of the patient. An innovative method able to avoid these obstacles is represented by controlled release systems for active substances. The interest for these systems came with allowing encapsulation in the antibiotic release matrices, local anesthetics, protein or other substances. Moreover, a number of such vehicles are now available to release controlled substances used predominantly in the anesthesia and intensive care unit.
... Creşterea biodisponibilităţii acestor compuşi lipozomiali s-a realizat prin grefarea de polietilenglicol. Lipozomii astfel funcţionalizaţi cu polietilenglicol [25,48] deţin proprietăţi semnificative pentru interacţiunea cu proteinele şi celulele organismului uman şi au un efect important asupra capacităţii de eliberare controlată de anestezic local [48,50,51]. ...
... Complexul format din levobupivacaină şi maltozilβ-ciclodextrină a redus neurotoxicitatea agentului anestezic după anestezia spinală. Există numeroase studii referitoare la combinarea agenţilor anestezici în formă bazică sau sub formă de sare în concentraţii de 0,02%, cu α-ciclodextrina, β-ciclodextrina sau γ-ciclodextrina [33,50,51]. Au fost obţinute astfel diverse sisteme capabile să elibereze controlat, gradual agentul anestezic local -geluri, uleiuri, supozitoare sau plasturi. ...
In the last decades, a series of active substances with important therapeutic effect were discovered, but drug administration problems persisted, such as: under- or over-concentration of the biological active drug in the body, inadequate response to treatment, increased patient discomfort etc. To limit these obstacles in obtaining a positive clinical response, a new delivery of the active substance in the body was developed – controlled release system of active substances. Controlled-release systems can be used in most clinical treatments by encapsulation of active substances: local anaesthetics, narcotics, proteins etc. in various ‘vehicles’, thus being of interest to anaesthesia and intensive care units.
... Bone grafting or bone harvesting is a procedure to augment deficient bone tissue and is widely used in a number of oral and maxillofacial procedures such as reconstructive surgical interventions [1][2][3][4]. Functional and structurally sound bone volume is essential for the reconstruction of alveolar defects. For this reason, the iliac crest, calvarium, tibia, fibula, and ribs have been used as extraoral donor sites for bone augmentation procedures in the field of oral and maxillofacial surgery [5,6]. ...
In this study, we aimed to quantitatively monitor and describe the gait functions of patients, who underwent iliac crest bone grafting in atrophic jaw augmentation operation, by taking into account the alterations of gait parameters and muscle forces in the early recovery course. To do so, temporospatial and kinematic gait parameters of ten patients during pre- and postoperative periods were recorded, and forces of the gluteus medius, gluteus maximus, and iliacus muscles were calculated. Three postoperative periods were specified as one week (post-op1), two weeks (post-op2), and three weeks (post-op3) after the surgery. Restoring process of the gait patterns was comparatively evaluated by analyzing the gait parameters and muscle forces for pre- and postoperative periods. Temporospatial and kinematic parameters of post-op3 were closer to those obtained in pre-op than those in post-op1 and post-op2 ( p<0.05 ). Muscle forces calculated in post-op3 showed the best agreement with those in pre-op among the postoperative periods in terms of both magnitude and correlation ( p<0.05 ). In conclusion, the patients began to regain their preoperative gait characteristics from the second week after surgery, but complete recovery in gait was observed three weeks after the surgery.
... Local analgesia has been shown to reduce immediate perioperative pain and graft site pain for up to 20 weeks. 19,20 In this study, 10 mL of 0.5% bupivacaine was injected into the bone graft site, which may have contributed to a reduction in shortand intermediate-term pain rates. ...
Anterior cervical decompression and fusion is a commonly performed procedure for cervical pathology. Graft choices include autograft, allograft, xenograft, synthetic, or a combination. Autograft has been shown to increase fusion rate compared with allograft, yet high morbidity at the harvest site has been reported. Few studies have evaluated chronic graft site pain, and to the authors' knowledge, no study has evaluated morbidity of a pilot hole burr technique for anterior iliac crest harvest. The objective of this study was to evaluate chronic morbidity of anterior iliac crest harvest in anterior cervical decompression and fusion using a pilot hole burr technique. A phone survey was used to identify chronic morbidity. Number of levels fused, age, sex, and acute graft site complications were explored to evaluate impact of patient characteristics on chronic graft site pain. A total of 140 patients met inclusion criteria; 106 patients (76%) completed the phone survey. Mean follow-up was 38.9 months. Two patients (1.9%) reported current and constant graft site pain. Nine patients (8.5%) reported intermittent pain. Average numeric pain rating scale score for survey participants was 0.25 of 10. No patients were taking narcotics for graft site pain. Two patients (1.9%) reported functional impairment secondary to the graft site pain. There was no impact of number of levels fused, age, sex, or acute graft site complications on chronic graft site pain. The pilot hole burr technique resulted in low long-term morbidity and may offer an alternative to traditional methods for those wishing to use autologous graft in anterior cervical decompression and fusion. [Orthopedics. 2019; 42(1):e68–e73.]
... A relationship between pain reduction and LOS reduction has been reported in RCTs with various postoperative populations. [51][52][53] However, in this study they held LOS constant, suggesting that reductions in pain, while they may have reduced LOS, led to reductions in cost for other reasons that are not yet understood. The relationship between LOS and cost has been found to be nonlinear, with earlier days in the stay being more expensive. ...
Objectives:
An important task facing hospitals is improving pain management without raising costs. Integrative medicine (IM), a promising nonpharmacologic pain management strategy, is yet to be examined for its cost implications in an inpatient setting. This institution has had an inpatient IM department for over a decade. The purpose was to examine the relationship between changes in patients' pain, as a result of receiving IM therapy, and total cost of care during an inpatient hospital admission.
Design:
In this retrospective analysis, data from an EPIC-based electronic health record (EHR) patient demographics, length of stay (LOS), and All Patient Refined Diagnosis Related Groups (APR-DRG) severity of illness measures were utilized. IM practitioners collected and entered patient-reported pain scores into the EHR. The authors regressed the demographic, change in pain, LOS, and APR-DRG variables with changes in pain on total cost for the hospital admission. To estimate cost savings to the hospital, they computed the average reduction in cost associated with reduction in pain by multiplying the coefficient for change in pain by average total cost.
Setting/location:
A large, tertiary care hospital in Minneapolis, MN.
Subjects:
Adult inpatient admissions, 2730, during the study period where patients received IM for pain and met eligibility criteria.
Intervention:
IM services provided to inpatients.
Outcome measures:
Change in pain on an 11-point numeric rating scale before and after initial IM sessions; total costs for hospital admissions.
Results:
Both LOS and age were found to increase cost, as did being white, male, married, and having APR-DRG severity coded as extreme. For patients receiving IM therapies, pain was reduced by an average of 2.05 points and this pain reduction was associated with a cost savings of $898 per hospital admission.
Conclusions:
For patients receiving IM therapies, pain was significantly reduced and costs were lowered by about 4%.
... Femoral nerve block was used for extracapsular femoral neck fracture by Haddad and Williams in 1995. 2 Dashow, Coulthard, Hoard, Sbitany, Haenel and Furst studied the effect of bupivacaine as a local anesthetic for pain control and morbidity reduction of iliac bone harvesting sites, rib fractures and temporomandibular joint arthroscopy. [3][4][5][6] In maxillofacial field, bupivacaine has been used as a safe local anesthetic solution for pain control after cleft lip operation or third molar surgery, alone or in combination with low-power laser and diclofeanc. [7][8][9][10][11][12][13] Bupivacaine is a well-known long-acting local anesthesia solution. ...
Background and aims. Postoperative pain control is extremely important for both patients and surgeons; in this context, long-acting local anesthesia can play an important role after open reduction of maxillofacial fractures. The purpose of this study was to evaluate the effect of bilateral mental nerve block with bupivacaine on postoperative pain control in mandibular symphyseal fractures.
Materials and methods. Fifty patients with pure mandibular symphyseal fractures were studied in two control and study groups. In contrast to the control group, the study group received bilateral mental nerve block with bupivacaine postoperatively. Patients were examined in relation to pain severity and opioid analgesic drug need sequences.
Results. The study group needed significantly less opioid than the control group (P<0.01, U=141). The control and study groups were different in first opioid administration time. The control and study groups received first opioid dose in 0-2 and 2-4 hours, respectively.
Conclusion. Bilateral mental nerve blocks with bupivacaine can reduce opioid analgesic need and it has a positive effect on postoperative pain control in mandibular symphyseal fractures.
... Patients are commonly anxious about oral surgery because of the anticipated post-operative pain, and we know that patients with high preoperative anxiety will experience more pain post-operatively than those with less preoperative anxiety, so patient education is therefore an important aspect of pain management [75][76][77] . In addition, and perhaps surprisingly, patients have more surgical complications if they have higher preoperative anxiety [78][79][80] . ...
AimTo describe the scientific basis of the contemporary management of pain after oral surgery. Materials and methodsA review of the literature describing the concepts of pre-emptive and protective analgesia and evidence-based practice in the context of managing pain after oral surgery. ResultsPain is the consequence of the interplay of numerous chemical mediators and a dynamic and plastic neuronal system, and so pain prevention and management requires the use of different classes of analgesic that act by different mechanisms and at different sites of action, ideally resulting in synergistic analgesia with few side effects. Conclusions
Management can be challenging, particularly as much oral surgery is undertaken on an outpatient and day-case basis, but significant improvement can be made to the patient's experience by considering the underlying mechanisms.
... Use of bupivacaine that offers anaesthesia for 6e8 h would be the obvious choice for management of postoperative pain. 17 Whilst there were fewer patients experiencing pain for more than 50% of the time from operation to discharge after the protocol change, it was of concern that about 12% of patients experienced pain for from three-quarters to all of the time from surgery to hospital discharge. ...
To reduce the number of patients experiencing severe postoperative pain by prescribing 10 mg Morphine either as oral solution or by IM injection as an alternative to Tramadol Hydrochloride in an analgesic protocol.
Patients who received in-patient oral and maxillofacial surgery under general anaesthesia were included. Complex intervention analgesic protocols were developed including staff education, patient educations and analgesic protocols. 80 patients were treated under the original protocol (tramadol hydrochloride for pain unmanaged by other drugs in protocol) over 4 months. 75 patients were treated under the second protocol (oral or intravenous morphine for pain unmanaged by other drugs in protocol). Patient perceptions to their pain management were then assessed.
Proportion of patients reporting 'no pain' increased from 5% of 80 patients to 28% of 75 patients (p < 0.001). Report of severe pain reduced from 37% to 31% and not significant. Pain duration reduced from 18% to 12% for 75-100% time from surgery to discharge and not significant. Staff used protocols for 96% patients. Nurses provided patient information leaflets for 85%-80% patients. Nearly all patients (96% and 95%) reported overall satisfaction with their pain management.
The use of morphine given orally or my IM injection rather than tramadol was associated with a significant increase in the number of patients reporting 'no pain'. However the number of patients experiencing severe pain was not significantly reduced. Despite this, most patients reported high levels of satisfaction which suggested that satisfaction questionnaires should not be used in isolation. Most patients received morphine orally rather than by IM injection but the oral dose may not have been high enough in this study.
Introduction
Pain after the alveolar bone graft (ABG) procedure can be difficult to manage. The goal of this study is to assess the described outpatient ABG protocol by comparing outcomes between pain catheters and local nerve blocks.
Methods
A retrospective single-institution review was conducted on patients with autologous iliac crest bone grafts (ICBGs). At the donor site, patients either receive on-Q continuous ropivacaine pain catheters or a local nerve block. Various outcomes such as postoperative pain medications used, postoperative pain scores, length of stay (LOS), and complications were compared between the 2 groups.
Results
Of the 79 patients that met our inclusion criteria, 60 (75.9%) received pain catheters and 19 (24.1%) received nerve blocks. Postoperative use of opioids and nonopioid medications such as acetaminophen and ibuprofen was similar between the 2 groups. The nerve block group reported a lower median pain score postoperatively than patients who received a pain catheter (5.0 versus 1.0, P =0.008). The overall complication rate was 2 (3.3%) for the pain catheter group due to pump failure and zero for the nerve block group.
Conclusion
Pain catheters and local nerve blocks are both safe methods of local anesthesia with low complication rates. However, pain catheters create concern for leakage or pump failure and a higher burden of care for patients and families. In addition, patients with nerve blocks report lower pain scores. As such, we have gradually shifted our practice toward the use of nerve blocks for an improved patient experience.
This chapter reviews the published literature for randomized controlled trials in oral and maxillofacial surgery. Two-hundred-thirty-two studies were included and the content is divided into eight categories: general medicine and oral surgery, outpatient anesthesia, dentoalveolar surgery, orthognathic surgery, facial trauma, pathology, reconstruction, and temporomandibular disorders. Key findings are summarized in a table format in each section, and the study quality was assessed in several ways: sample size and number of enrolling institutions, risk of bias in four different domains, and whether the study used a standard diagram to illustrate study enrollment and data collection. Most investigations were single-center studies (94%) with a median sample size of 46 subjects. Bias was a significant concern since the vast majority of studies had either a moderate risk (66%) or high risk (28%) of bias based on Cochrane assessment tools.
The content and quality analyses are then expounded upon by discussing gaps and common pitfalls in the current body of literature. The goal of this discussion is to give concrete recommendations on both design and content to today’s aspiring surgeon–scientist to carry out the studies needed in this field. Major recommendations include a sample size greater than 70 subjects, multicenter collaboration, and inclusion of fundamental details of methodology: randomization techniques, baseline differences among study arms, subject adherence to assigned treatment, blinding status of evaluators, and completion of patient follow-up. The principle of clinical equipoise should guide surgeon–scientists to find the balance between intellectual curiosity and therapeutic obligations. Lastly, both the physiology and logistics of a given disease process or intervention may influence how easily it is studied using a randomized controlled trial; other study designs may still be indicated for outcomes that are rare, take a very long time to assess, or in diseases with a known best simple treatment.
Background: The optimal prevention and treatment of pain associated of iliac crest bone graft donor sites for the treatment of cleft alveolus defects has not been well characterized. The aim of this study is to assess the efficacy of minimal access bone graft techniques with or without regional anesthesia in iliac crest bone harvest and compare to outcomes to traditional open harvest techniques. Methods: A retrospective review of 46 patients undergoing iliac crest bone harvest using traditional open iliac crest bone graft (ICBG) alone (Group 1, n = 20), minimal access ICBG (Group 2, n = 20), or minimal access ICBG with paravertebral anesthetic block (Group 3, n = 5) was performed. Post operative pain scores, narcotic consumption, and hospital stay were analyzed. Results: The average time to first narcotic was 247 minutes in Group 1, 193 in Group 2, and 1162 minutes in Group 3 ( P < .0002). Total narcotic use was 0.117 mg/kg in Group 1, 0.131 mg/kg in Group 2, and 0.072 mg/kg in Group 3. The average pain score (VAS) was 2.96 in Group 1, 1.83 in Group 2, and 1.08 in Group 3 ( P < .01). The average length of stay was 1.45 for Group 1, 1.36 for Group 2, and 1.0 for Group 3. Bone graft extrusion occurred in 6 patients (27.3%) in Group 1 and none in Group 2 or 3. There were no wound infections, bleeding requiring reoperation, or mortalities. Conclusion: The addition of regional anesthesia to minimal access alveolar bone graft harvest significantly reduces time to first narcotic use. Although not significant, a strong trend was found with regional anesthesia to lower the pain score (VAS) and total narcotic use. Regional anesthesia did not significantly reduce the length of hospital stay compared to either group. Minimal access techniques with supplemental regional anesthesia significantly lowered the pain score and time to first narcotic and trended to decreased length of hospitalization and total narcotic use compared to traditional open techniques.
Background:
Suboptimal pain management is a common, yet largely unrecognized, problem in the postsurgical patient population. Current treatment protocols heavily rely on opioid use and, though generally effective in providing pain relief, are associated with multiple side effects. The present systematic review aims to offer plastic surgeons insight into the current state of literature on prolonged local anesthetic wound infusion regimens, evaluating both their efficacy in lowering pain scores and the potential opioid-sparing effect.
Methods:
A comprehensive literature search of the Medline, Embase, and Cochrane Library databases was performed to identify relevant studies published between 1980 and December 2017 evaluating the use of prolonged local anesthetic wound infusion for postoperative pain management in plastic surgery.
Results:
A total of 28 articles were selected, including 3904 patients. The overall infection rate in all patients treated with postsurgical local anesthetic wound infiltration was 0.28% (7/2536). There were no reported cases of systemic toxicity. An opioid-sparing effect was found in 92% (12/13) of studies when compared to an active comparator and 88% (7/8) of those comparing to placebo. Pain scores were decreased in 90% (9/10) of studies comparing wound infiltration to narcotic-based regimens and in 67% (6/9) of those comparing to placebo.
Conclusions:
Continuous or intermittent wound infusion is safe and effective in reducing pain scores and opioid consumption in plastic surgery. Though the overall pain-lowering effect appears to be modest, ease of catheter insertion and patient satisfaction make this technique an alluring alternative to more validated approaches such as neuraxial or peripheral nerve blocks.
The aim of this study was to compare the analgesic effects of ropivacaine and levobupivacaine in continuous infiltration anaesthesia delivered via a multiple-hole catheter for the purpose of postoperative analgesia after iliac bone grafting. Thirty-four patients scheduled for iliac bone grafting in the maxillofacial region participated in this study. The patients were randomized to a ropivacaine group (Ropi group) and a levobupivacaine group (Levo group). After harvesting the iliac bone for grafting, a multiple-hole catheter was placed on the periosteum of the iliac bone. When surgery was completed, continuous administration was started at 4ml/h of 0.2% ropivacaine (Ropi group) or 0.25% levobupivacaine (Levo group). Pain was evaluated in the recovery room and at 4h after surgery, as well as at 9:00 and 18:00 on postoperative days 1, 2, and 3, using a visual analogue scale. Side effects were also recorded. No significant difference in the visual analogue scale scores at rest or in motion was observed between the two groups. In addition, there were no side effects in the two groups. Both 0.2% ropivacaine and 0.25% levobupivacaine provided comparable analgesic effects in continuous infiltration anaesthesia delivered via a multiple-hole catheter after iliac bone grafting.
Objective:
Alveolar bone grafting (ABG) with iliac crest bone graft can be associated with significant pain at the donor site. The On-Q pain pump has been shown to be efficacious in treating postsurgical pain. The aim of this study was to compare the length of postoperative hospital stay in patients undergoing ABG who received the On-Q pain pump at the iliac crest donor site (On-Q+) with that of patients who did not receive the On-Q pain pump (On-Q-).
Design:
A retrospective, cohort study, approved by institutional review board, was performed. Thirty-one consecutive patients in the On-Q- group were compared with 38 consecutive patients in the On-Q+ group. The two cohorts were assessed for length of stay. Statistical analysis was performed using the Fisher exact probability test.
Setting:
Tertiary care academic medical center.
Patients:
Sixty-nine patients with cleft lip and/or cleft palate (CL/P) undergoing secondary ABG with iliac crest bone graft were operated on between May 1993 and January 2014.
Main outcome measure:
Length of postoperative hospital stay.
Results:
Mean length of stay in the On-Q- patients was 0.52 days versus 0.37 days for the On-Q+ patients. This difference between the two cohorts was not statistically significant (P = .234).
Conclusion:
Although there is a trend toward a shorter length of stay in our patients who received the On-Q pump, this finding was not statistically significant. Given the expense and additional burden of care associated with the device, we have become more selective in its utilization.
INTRODUCTION: Harvesting bone graft from the iliac crest in spinal fusion surgery is a widely used technique. However, complications can occur and there are also reports of patients with persistent graft site pain after surgery. The aim of this study was to evaluate pain from the donor site (DS) over time, and register associated complications and if it affected health-related quality of life (HRQoL). MATERIAL AND METHODS: One hundred and seven patients participating in an RCT between two different methods of reconstruction after cervical decompression were included in this study. One group underwent surgery with bone graft (BG) from the iliac crest and the other with no bone graft (NBG). All patients were evaluated concerning pain at DS and HRQoL preoperatively, at 4 weeks, 3 months and 1 year. Pain was evaluated with visual analog scale (VAS) and HRQoL with EQ-5D. RESULTS: A statistically significant difference was found at all times of follow-up in the BG group compared to preoperative levels and the NBG group. The VAS levels at follow-ups at 3 months and 1 year were however of questionable clinical importance. Two patients in the BG group had superficial wound infections postoperatively and five patients still had sensory disturbance in the area of graft site at 12 months. No major complications were registered. No difference could be seen in EQ-5D at any time of follow-up between the groups. CONCLUSION: Harvesting of iliac crest bone graft is associated with significant pain. However, at 3 months postoperatively, the negative effect of clinical importance seemed to have disappeared compared to when no bone graft was harvested. The pain from bone graft harvesting does not seem to affect the quality of life at 4 weeks postoperatively and onward.
This review article describes the scientific basis of contemporary management of pain after oral surgery. Management can be challenging but significant improvement can be made to the patient's experience by patient education, staff education and the use of an evidence-based analgesic protocol.
Harvesting of iliac crest graft for spinal fusions is associated with a number of patients reporting residual or chronic pain at the harvest site. Various interventions, including morphine infiltration, have been proposed to minimize the associated pain.
We performed a prospective, double-blind, randomized, placebo-controlled study comparing intraoperative infiltration of 5 mg morphine (treatment) versus saline (placebo) into the iliac crest harvest site for patients undergoing elective spinal surgery. Patients with myelopathy, excessive perioperative opioid use (60 mg equivalent morphine/d or more), or multilevel (>3 levels) spinal surgery were excluded. Postoperative administration of morphine (recovery room and patient-controlled analgesia) was standardized. Numerical pain scores specific for the iliac crest site were determined in the immediate postoperative period and at 3, 6, and 12 months.
Of the 54 patients randomized, 47 (87%) were available for review with a minimum of 1-year follow-up. The groups were similar in baseline age, gender, and comorbidities. There was no significant difference between groups in total use of postoperative morphine during the first 24 hours (P = 0.48). Repeated measures analysis of variance demonstrated no interacting effect of group over time for hip pain at rest (P = 0.94), hip pain while moving (P = 0.90), spine pain at rest (P = 0.99), or spine pain while moving (P = 0.83). The proportion of patients reporting iliac crest pain at 1-year follow-up was the same between groups (P = 0.95).
This study has demonstrated that there are no additional benefits for the use of intraoperative infiltration of morphine into the iliac crest harvest site during spinal fusions.
Observational gait analysis is clinically useful with videotape slow-motion replay and freeze-frame, offering significant improvement over unaided visual observation. Any form of observational gait analysis, however, has limited precision and is more descriptive than quantitative. This article reviews procedures that are available for gait analysis. Gait analysis systems have evolved from cine with manual digitization, electrogoniometry, and video technology to sophisticated automated tracking systems. When used in conjunction with biomechanical models, these systems allow quantitative analysis of many specific gait characteristics such as joint moments and powers (kinetic analysis), joint angles, angular velocities, and angular accelerations (kinematic analysis). Analysis of dynamic electromyographic activity and energy consumption adds useful clinical information to gait analysis. The combination of a careful clinical assessment and gait analysis can be a powerful tool for the clinician.
This two-part review summarizes the current knowledge of physiological mechanisms, pharmacological modalities and controversial issues surrounding preemptive analgesia.
Articles from 1966 to present were obtained from the MEDLINE databases. Search terms included analgesia, preemptive; neurotransmitters; pain, postoperative; hyperalgesia; sensitization, central nervous system; pathways, nociception; anesthetic techniques; analgesics, agents. Principal findings: In Part I of this review article, techniques and agents that attenuate or prevent central and peripheral sensitization were reviewed. In Part II, the conditions required for effective preemptive techniques are evaluated. Specifically, preemptive analgesia may be defined as an antinociceptive treatment that prevents establishment of altered central processing of afferent input from sites of injury. The most important conditions for establishment of effective preemptive analgesia are the establishment of an effective level of antinociception before injury, and the continuation of this effective analgesic level well into the post-injury period to prevent central sensitization during the inflammatory phase. Although single-agent therapy may attenuate the central nociceptive processing, multi-modal therapy is more effective, and may be associated with fewer side effects compared with the high-dose, single-agent therapy.
The variable patient characteristics and timing of preemptive analgesia in relation to surgical noxious input require individualization of the technique(s) chosen. Multi-modal analgesic techniques appear more effective.
A randomized prospective double-blinded study was conducted in 100 patients suffering from mono- or bisegmental cervical retrospondylosis or disc herniation.
In group I, 50 patients were treated by injection of 10 ml Ropivacaine 7,5% at the iliac crest bonegraft donor site. Local anaesthetic (LA) was injected through the wound drainage after closure of the muscle fascia, the suction drainage was opened after closure of the skin. Group II was treated with 0,9% saline. Operator and patient were blinded to the injected substance. Daily controls of pain intensity were made with the 10 cm visual analog scale from 0 (no pain) to 10 (severe pain) for 5 days. All patients were questioned regarding pain character and movement provoking pain. Additional pain medication was standardized.
Statistical analysis of mean pain intensity over the whole hospital stay showed a significant difference in pain intensity between the two groups (p = 0,017, Chi-Square test). The comparison between pain intensity with LA and without LA showed a gradual increase in statistical significance from day 1 to day 5 (day 1: p = 0,54, not significant; day 2: p = 0,026; day 3: p = 0,008; day 4: p = 0,004; day 5: p = 0,002).
This data shows that intra-operative blockage of peripheral nociceptive structures results in decreased pain at later time points. We conclude that wound infiltration with 7,5% Ropivacaine after bonegraft removal at the iliac crest is effective in reducing postoperative pain.
Observational gait analysis is clinically useful with videotape slow-motion replay and freeze-frame, offering significant improvement over unaided visual observation. Any form of observational gait analysis, however, has limited precision and is more descriptive than quantitative. This article reviews procedures that are available for gait analysis. Gait analysis systems have evolved from cine with manual digitization, electrogoniometry, and video technology to sophisticated automated tracking systems. When used in conjunction with biomechanical models, these systems allow quantitative analysis of many specific gait characteristics such as joint moments and powers (kinetic analysis), joint angles, angular velocities, and angular accelerations (kinematic analysis). Analysis of dynamic electromyographic activity and energy consumption adds useful clinical information to gait analysis. The combination of a careful clinical assessment and gait analysis can be a powerful tool for the clinician.
Background. Substitutes for bone graft have been advocated to avoid the potential morbidity associated with harvest of autogenous iliac crest graft. However, no current commercially available graft equals autogenous bone's osteoinductive and osteoconductive qualities. We reviewed our patients' morbidity after harvest of anterior iliac crest bone grafts for procedures involving the foot and ankle. Methods: A computerized analysis of patient records was undertaken to identify all patients who had a harvest of unicortical iliac crest bone graft during a 12-year period. Patients were contacted either by telephone or by mailed questionnaire, inquiring about the postoperative morbidity of the procedure. Medical records were reviewed for any related complications. Results: Of the 169 patients identified, 134 could be contacted. Follow-up ranged from I to 13 years. Not all patients answered every question. At latest follow up, 120 (90%)-patients reported no pain at the bone graft site. Eleven patients complained of persistent residual numbness lateral to the harvest site on the pelvis. Of these 120 patients, 32 (27%) reported that pain at the graft site was greater than the pain at the operative site during the initial postoperative period. No patients had extra hospital days as a result of the bone graft harvest. No deep infections occurred, although 12 (6.7%) of 180 patients had a postoperative hematoma or seroma. Overall, 116 (90%) of 129 patients were satisfied or very satisfied with their bone graft harvest. Conclusions: Harvesting of autogenous iliac crest bone graft provides the optimal bone graft material, yields minimal morbidity, and is an acceptable choice in supplementing surgical procedures on the foot and ankle.
Study Design. A prospective study was conducted to examine bone graft donor site morbidity in 106 consecutive patients undergoing posterior spinal fusion. Objectives. To perform a prospective analysis of donor site morbidity, to document the incidence of major complications, and to collect information on the impact of autologous bone graft harvesting from the posterior iliac crest on the overall outcome of spinal surgery. Summary of Background. Bone graft harvesting from the posterior iliac crest for spinal fusion is a source of significant morbidity. Previous retrospective case studies indicate that minor complications are common, but they do not define the natural history and complications of posterior iliac crest bone graft harvesting. Methods. A standardized harvesting technique was used. At 3, 6, and 12 months after surgery, the patients completed a proforma questionnaire rating symptoms on a visual analog scale and underwent a postoperative examination by the surgeon. Finally, overall surgical outcome was assessed at 12 months. Results. The major component of morbidity is donor site pain. Mean pain scores were 1.640 at 3 months, 1.812 at 6 months, and 1.207 at 12 months. The pain at 12 months was significantly less than at 3 and 6 months (P = 0.005), with a trend toward the highest scores at 6 months. A pain score of 0 was reported by 55% of the patients. Local sensory loss was found in 10% of the patients. Outcome assessment showed significant differences in morbidity for surgery performed at different spinal levels (P = 0.001), with lumbosacral surgery resulting in worse outcomes than either cervical (P < 0.05) or thoracolumbar (P < 0.05) surgery. Significantly higher visual analog scores were observed at 6 months in patients with poorer overall outcomes. Conclusions. According to this study, it is reasonable to reassure patients that a good result from spinal surgery will not be compromised by severe symptoms or major morbidity secondary to posterior iliac crest bone graft donation. Before surgery, patients may be advised concerning the risks of donor site pain, which improves significantly by 12 months, local tenderness, and uncommonly localized sensory loss.
Ropivacaine (Naropin®) is the pure S(−)-enantiomer of propivacaine, and is a long-acting amide local anaesthetic agent, eliciting nerve block via reversible inhibition of sodium ion influx in nerve fibres.
Ropivacaine is a well tolerated regional anaesthetic effective for surgical anaesthesia as well as the relief of postoperative and labour pain. The efficacy of ropivacaine is similar to that of bupivacaine and levobupivacaine for peripheral nerve blocks and, although it may be slightly less potent than bupivacaine when administered epidurally or intrathecally, equi-effective doses have been established. Clinically adequate doses of ropivacaine appear to be associated with a lower incidence or grade of motor block than bupivacaine. Thus ropivacaine, with its efficacy, lower propensity for motor block and reduced potential for CNS toxicity and cardiotoxicity, appears to be an important option for regional anaesthesia and for the management of postoperative and labour pain.
Pharmacological Properties
Like other local anaesthetics, ropivacaine elicits nerve block via reversible inhibition of sodium ion influx in nerve fibres. The pKa of ropivacaine is similar to that of bupivacaine and levobupivacaine (≈8.2) but, unlike racemic bupivacaine, ropivacaine is the pure S(−)-enantiomer of propivacaine. It has lower lipid solubility and is less likely than bupivacaine to penetrate large, myelinated motor fibres. The degree of ropivacaine-induced sensory and motor block are dose- and age-dependent.
Despite the lower potency (based on minimum local anaesthetic concentrations) of ropivacaine than bupivacaine or levobupivacaine at lower doses, such as those used for epidural or intrathecal analgesia, ropivacaine has similar efficacy to these agents at higher doses such as those used for peripheral nerve block.
As with other local anaesthetics, ropivacaine has the potential to induce cardiovascular toxicity (e.g. arrhythmias and reduced myocardial conductivity and contractility) and CNS toxicity (e.g. seizures) at high plasma concentrations such as those occurring after large doses or inadvertent intravascular administration. It has a significantly higher threshold for cardiovascular and CNS toxicity than bupivacaine in animals and healthy volunteers.
Ropivacaine displays linear and dose-proportional pharmacokinetics up to 80mg (when administered intravenously). Absorption from the epidural space is complete and biphasic; the first phase (half-life [t;] 14 minutes) is followed by a slower second phase (t; 4.2 hours). Ropivacaine is extensively protein bound and crosses the placenta during epidural administration for Caesarean section. It is metabolised in the liver and excreted in the urine.
Therapeutic Efficacy
Randomised, double-blind, comparative clinical trials in adults have demonstrated the efficacy of ropivacaine in providing a profound sensory and motor block suitable for anaesthesia and a sensory/motor block profile suitable for postoperative or labour pain when administered by various routes (principally epidural or intrathecal administration and peripheral nerve block).
For epidurally administered surgical anaesthesia, ropivacaine and bupivacaine have similar efficacy, whereas with epidural administration for postoperative or labour analgesia, where doses required are lower than those needed for anaesthesia, ropivacaine has a shorter-lasting sensory block as well as a lower incidence/ degree of motor block than bupivacaine; equipotent doses have been established.
The duration of analgesia was less with ropivacaine than bupivacaine when administered intrathecally for anaesthesia or labour pain relief, but the duration of sensory block is still adequate for anaesthesia and the quicker regression of the motor block encourages mobilisation and recovery.
Peripheral nerve block for anaesthesia in orthopaedic surgery and for postoperative pain relief requires the use of relatively high doses of regional anaesthetic agents and the potency differences between ropivacaine and bupivacaine that were evident with epidural or intrathecal administration were not observed with this route of administration.
Ropivacaine and levobupivacaine are generally similarly effective for the above indications and routes of administration.
In children aged <12 years, ropivacaine provided effective postoperative pain relief when administered as a caudal or lumbar epidural injection, as a continuous epidural infusion or as a peripheral nerve block. The analgesic efficacy of ropivacaine was similar to that of bupivacaine and levobupivacaine; however, postoperative motor blockade was significantly less in ropivacaine than in bupivacaine recipients.
Tolerability
Ropivacaine is generally well tolerated regardless of the route of administration. Adverse events that occurred in ≥5% of patients in clinical trials who received ropivacaine 0.125–1% via various routes of administration for surgery, labour, Caesarean section, postoperative pain management, peripheral nerve block or local infiltration were hypotension (32%), nausea (17%), vomiting (7%), brady-cardia (6%) and headache (5%). Epidural administration of ropivacaine for surgery produced dose-dependent adverse events similar to those observed with equal doses of bupivacaine. Ropivacaine is generally well tolerated in the fetus or neonate following maternal epidural administration. The incidence of cardiovascular and CNS toxicity as a result of inadvertent intravascular injection of ropivacaine appears to be low.
The tolerability of ropivacaine in children (aged from 1 month to 15 years) appears to be at least similar to that of bupivacaine or levobupivacaine and is generally good, regardless of the route of administration. The most frequently occurring adverse events were nausea and vomiting.
Bone grafting is a surgical technique for the reconstruction of the atrophic edentulous maxilla prior to treatment with endosseous implants. The anterior iliac crest is a commonly used donor site.
The aim of this study was to evaluate the donor site morbidity and complications when harvesting corticocancellous bone from the medial table of the anterior iliac crest and compare this with results when bone was harvested from the lateral and superior table of the anterior iliac crest. In addition, the outcome of the oral rehabilitation was evaluated by means of a quality-of-life questionnaire.
The study was composed of 70 consecutively treated patients with a mean age of 56 years. The patients were retrospectively evaluated with regard to postoperative donor site morbidity and complications at the donor site.
For the donor site morbidity, 74% of the patients were free of pain within 3 weeks, whereas 26% of the patients had a prolonged period of pain lasting from a few weeks to several months. For 11% of the patients, there was still some pain or discomfort 2 years after the grafting surgery. For gait disturbance the figures were similar: 79% had no problems after 3 weeks. For the eight patients who still had some pain after 2 years, which was considered permanent, three also had gait disturbance. There was a total of three major complications (4%), one iliac wing fracture and two neurologic injuries.
When harvesting a large amount of unicortical corticocancellous bone blocks from the the superolateral site of the iliac crest with a "peel off" technique, morbidity and complication rates do not differ significantly compared with those of the traditional anterior medial approach. Oral rehabilitation with maxillary reconstruction with bone grafts from the iliac crest and endosseous implants significantly improved oral function, facial appearance, and recreation/social activities and resulted in an overall improvement in quality of life in formerly edentulous patients.
To explore the relationship between surgical approach and chronic posterior iliac crest donor site pain, 151 bone graft harvests with follow-up periods longer than 1 year were evaluated using a detailed questionnaire and follow-up clinical visits. There was no difference in the incidence of chronic donor site pain between harvests performed through the primary midline incision versus a separate lateral oblique incision (28 vs 31%). Twice as many donor sites harvested for reconstructive spinal procedures were reported as having chronic pain as compared with those harvested for spinal trauma, regardless of approach used (39 vs 18%). The association of chronic donor site pain with residual back pain was also greater in the spinal reconstructive group. Thus, it appears that incidence of chronic donor site pain is more dependent on diagnosis than on surgical approach.
A short review of the literature is presented outlining the role of alveolar bone grafting in cleft patients. An analysis of a series of 47 secondary alveolar bone grafts in 34 patients is presented. The age range was 7-24 years. At the time of evaluation, 30 canines were in final occlusion and good alveolar bone levels were present in 83% of patients. Of the 13 bilateral cases (26 clefts), 14 canines were in final occlusion and all cases had good alveolar bone levels. No major complications were encountered. The graft was completely resorbed in 3 cases (6.4%) only.
Autogenous bone grafts from the ilium are frequently harvested for purposes of bone union and/or stability. Although some donor site complications may be unavoidable, awareness of the anatomy and complications may aid in planning the approach and minimizing the risks. Documented donor site complications include pain, nerve and arterial injury, peritoneal perforation, sacroiliac joint instability, and herniation of abdominal contents through defects in the ilium. Strict observation of relevant anatomic considerations will help in avoiding these complications.
This study analyzed the cause, rate, and risk factors of iliac crest bone graft donor site morbidity.
All complications or problems, no matter how small, were sought to develop strategies of prevention.
A wide range of major, 0.76% (Keller et al) to 25% (Summers et al) and minor complications, 9.4% (Keller et al) to 24% (Summers et al) has been reported.
A consecutive series of 261 patients, whose bone graft harvest was done by one surgeon, was studied by chart review and a mail survey that was not conducted by the operating surgeon. The survey presented specific open-ended questions designed to uncover any complication/problem, no matter how small. Complications then were categorized as major or minor and subcategorized as acute or chronic. Statistical analysis was done using chi-squared and multiple logistical regression.
None of the 261 patients had a severe perioperative complication--e.g., superior gluteal artery injury, sciatic nerve injury, or deep wound infection. None of the 225 patients with long term follow-up (average, 66 months; range, 32-105 months) had a severe late complication--e.g., donor site herniation, meralgia paresthetica, pelvic instability, or fracture. Of the 180 patients meeting the qualifications for statistical analysis, major complications occurred in 18 (10%), only three of which affected function (pain). Minor complications occurred in 70 (39%).
The results indicated that severe complications from iliac crest bone graft harvest can be avoided and major complications affecting functioning are uncommon, but minor complications are common. The findings suggest that procedural refinements of limiting subcutaneous dissection and providing layered tension-free incision closure may improve results.
Twenty-eight patients underwent anterior iliac crest reconstruction after the harvesting of autogenous tricortical graft. The anterior iliac crest was reconstructed using the resected rib from the thoracoabdominal approach. The authors evaluated graft site pain and residual deformity, radiographic evidence of rib incorporation, and the incidence of lateral femoral cutaneous nerve injury. There were no reports of graft site pain greater than "acceptable" levels, requiring nonnarcotic analgesics on an intermittent basis and not interfering with activities of daily living. Four lateral femoral cutaneous nerve neuropraxias were recorded, none of clinical significance. The authors advocate the use of autogenous tricortical anterior iliac crest bone graft when performing reconstructive spinal surgery, followed by reconstruction of the iliac crest with the resected rib from the surgical approach.
The morbidity of bone harvest was compared between anterior lateral and medial surgical approaches in a randomized prospective study. Forty consecutive patients, each requiring a minimum 40 cc of loose corticocancellous bone for maxillofacial reconstruction, were randomly placed into two equal groups. Morbidity vectors assessed included bone volume, blood loss, length of surgery, length of hospital stay, incidence of seroma, incidence of anterior thigh paresthesia, postoperative pain, and gait disturbance. The results demonstrated no significant difference in morbidity between these two approaches; therefore selection of either approach is the surgeon's personal preference. A thorough understanding of the osseous anatomy of the anterior ilium and its muscular attachments, a good surgical technique, an efficient surgical team, and a continuous flow of required surgical instruments are essential to reduce the morbidity of bone harvest.
Anterior iliac crest donor site morbidity was analysed retrospectively at 154 sites in 137 patients who had undergone secondary bone grafting of the cleft alveolus. The applied surgical anatomy and operative technique utilizing a medially based osteoplastic flap are described. The results show a low incidence of donor site morbidity.
A method of local analgesic delivery to the donor site after the harvest of autogenous corticocancellous bone from the iliac crest is described. The technique reduces the need for postoperative systemic analgesia and facilitates early patient mobilization.
The authors studied the effect of immediate postoperative administration of bupivacaine in patients who underwent a lumbar decompressive procedure.
In this randomized double-blind trial, 50 patients who underwent elective lumbar decompression after induction of general anesthetic received a postoperative bilateral paravertebral 40-ml intramuscular application of either saline (0.9%) or bupivacaine (0.25%). For delivering morphine, both groups used a patient-controlled analgesia system for 24 hours postsurgery. Pain scores, 10-cm visual analog scale scores, and morphine consumption were similar between groups with no significant differences (p>0.05).
Results of subgroup analysis suggested strongly that perioperative administration of methylprednisolone in a sustained-release preparation was associated with a reduction in postoperative pain (p<0.05).
We questioned 75 patients after inpatient oral and maxillofacial operations to find out how satisfied they were with the extent to which their pain had been controlled. Seventy (93%) had had postoperative pain. In 33 (47%), it was moderate and in 24 (34%), severe. Analgesic drugs were not given immediately to 6 of the 24 patients who requested them. Seventeen (24%) reported that the pain was worse than they had expected, but 74 of the 75 patients were satisfied with the pain control they received. We conclude that patients' expectations of pain control are low and that questions about satisfaction should not be used in isolation.
A prospective study was conducted to examine bone graft donor site morbidity in 106 consecutive patients undergoing posterior spinal fusion.
To perform a prospective analysis of donor site morbidity, to document the incidence of major complications, and to collect information on the impact of autologous bone graft harvesting from the posterior iliac crest on the overall outcome of spinal surgery.
Bone graft harvesting from the posterior iliac crest for spinal fusion is a source of significant morbidity. Previous retrospective case studies indicate that minor complications are common, but they do not define the natural history and complications of posterior iliac crest bone graft harvesting.
A standardized harvesting technique was used. At 3, 6, and 12 months after surgery, the patients completed a proforma questionnaire rating symptoms on a visual analog scale and underwent a postoperative examination by the surgeon. Finally, overall surgical outcome was assessed at 12 months.
The major component of morbidity is donor site pain. Mean pain scores were 1.640 at 3 months, 1.812 at 6 months, and 1.207 at 12 months. The pain at 12 months was significantly less than at 3 and 6 months (P = 0.005), with a trend toward the highest scores at 6 months. A pain score of 0 was reported by 55% of the patients. Local sensory loss was found in 10% of the patients. Outcome assessment showed significant differences in morbidity for surgery performed at different spinal levels (P = 0.001), with lumbosacral surgery resulting in worse outcomes than either cervical (P < 0.05) or thoracolumbar (P < 0.05) surgery. Significantly higher visual analog scores were observed at 6 months in patients with poorer overall outcomes.
According to this study, it is reasonable to reassure patients that a good result from spinal surgery will not be compromised by severe symptoms or major morbidity secondary to posterior iliac crest bone graft donation. Before surgery, patients may be advised concerning the risks of donor site pain, which improves significantly by 12 months, local tenderness, and uncommonly localized sensory loss.
Autogenous iliac crest bone grafts are often used for persons undergoing anterior cervical fusion (ACF). Study findings have shown that pain at the iliac crest donor site can often be more severe than that at the primary operation site. A method used to eliminate pain after bone harvesting involves infiltration of a local anesthetic directly into the site. This study examined the efficacy of local anesthetic infiltration in the control of donor site pain, utilizing a randomized, double-blind, placebo-conrolled design. All participants received standard postoperative intravenous and oral analgesic. Those in the study group also received six injections of bupivacaine hydrochloride 0.25% into the donor site, while participants in the placebo group received normal saline injections. Participants receiving bupivacaine (n = 14) consistently reported lower hip pain scores than participants receiving the placebo (n = 8), with significant differences noted 3 hours after the first and second doses of the study drug. The bupivacaine group's mean morphine intake for the first 24 hours after surgery was found to be lower (32 mg; placebo 44 mg), whereas participants younger than 49 years who received bupivacaine were found, on average, to have stayed in the hospital one day less (3.6 days) than placebo group participants (4.5 days). Younger participants receiving bupivacaine required less morphine and had, on average, a reduced length of stay. The clinical implication of using local anesthetic for the relief of donor site pain suggests that it is a safe and efficacious technique.
A study which examined the morbidity experienced by patients who underwent iliac crest bone graft procedures.
A post-operative questionnaire was forwarded to patients who underwent iliac crest bone graft procedures at a single centre.
One hundred and fourteen patients underwent iliac crest bone grafts for intra-oral augmentation.
Ninety-eight patients (80%) returned post-operative questionnaires. Eighty of the 98 (81.6%) patients suffered post-operative pain with 70% of patients being pain-free after four weeks. However, 10% of patients experienced pain for more than 16 weeks. Eighty-five (86.7%) patients were able to walk without any difficulties six weeks post-operatively. Gait disturbance was not related with age, however there was a significant association between pain and disturbance of gait (P< 0.001). Twenty two patients required the use of a walking stick and the use of such aids varied from 0.5 to 26 weeks. Women used walking aids for longer periods than men (P< 0.05). Twenty five patients had altered sensation with about half of them experiencing altered sensation in the distribution of the lateral femoral cutaneous nerve. Other morbidities included deformity at the hip site (2.4%), haematoma (2.4%), infection (3.2%), stress fracture (4.1%) and meralgia paraesthetica in one patient. Despite the above morbidities, 82 patients were willing to undergo the same procedure again and 89 patients would recommend the procedure to their relatives and friends.
This study demonstrates considerable morbidity following anterior iliac crest bone harvest for intra-oral augmentation. Clinicians referring patients for such bone graft procedures must be aware of the above morbidities so that any patients referred for such procedures are fully informed.
It has been the aim of the present prospective clinical study to assess the morbidity following the harvest of bone from the anterior and posterior ilium in elective preprosthetic augmentations. Fifty consecutive healthy patients (30 female, 20 male, mean age 52.5+/-9.3 years, range 31 years to 65 years) underwent augmentations of implant sites by iliac crest bone grafts. The bone harvest was carried out in 25 cases from the anterior and in 25 cases from the posterior ilium. The superficial sensory function of the skin was determined quantitatively preoperatively, 7 and 30 days after surgery with the 'Pain and Thermal Sensitivity' Test (PATH Test). On the same occasions subjective pain on a visual analogue scale (VAS) and gait disturbances were documented. In the PATH Test, for the innervation areas of the lateral femoral cutaneous nerve (LFCN) and the superior and middle cluneal nerves (SMCN) a significant impairment of the superficial sensory function could be found after 1 week and a significant tendency towards recovery after 1 month (warm stimulus(FCNpreop) 37.9+/-3.0 degrees C, warm stimulus(LFCNday7): 38.6+/-3.2 degrees C, warm stimulus(LFCNday30): 37.9+/-2.9 degrees C, P(LFCNwarmpreop/day7)=0.023,P(LFCNwarmpreop/day30) =0.886, warm stimulus(SMCNpreop): 36.1+/-2.4 degrees C, warm stimulus(SMCNday7): 36.6+/-2.3 degrees C, warm stimulus(SMCNday30): 36.3+/-4.0 degrees C,P(SMCNwarmpreop/day7) <0.0005,P(SMCNwarmpreop/day30) =0.086). Gait disturbances were seen in seven patients after anterior and in three patients after posterior bone harvest 7 days after surgery (P(gaitdisturbanceanterior/posterior)=0.123). After 1 month none of the patients of both groups showed gait disturbances any longer. The maximum subjective pain level was found on the second postoperative day in both groups. It was significantly higher for the anterior approach (VAS(anteriorday2) 7.0+/-1.5, VAS(posteriorday2) 5.5+/-1.8,P(VASanterior/posteriorday2) =0.004). At day 7 and at day 30, the pain levels did no longer differ significantly (VAS(anteriorday7) 3.7+/-1.4, VAS(posteriorday7) 3.2+/-1.6,P(VASanterior/posteriorday7) =0.165, VAS(anteriorday30) 1.4+/-0.7, VAS(posteriorday30) 1.4+/-0.8,P(VASanterior/posteriorday30) =0.724). Because of the lower morbidity of bone harvest from the posterior ilium in the early postoperative phase compared to the anterior approach it seems that it should be preferred in elective augmentation procedures.
The aim of the study was to compare the efficacy of either ropivacaine or placebo through an iliac crest (IC) catheter after Bankart repair with IC bone grafting.
With approval of the local ethics committee and after written informed consent was obtained, 36 patients had an interscalene catheter placed preoperatively. Intraoperatively, the surgeon placed a catheter at the IC donor site. At the end of surgery, 30 ml ropivacaine, 0.5% (ropivacaine group), or 30 ml NaCl, 0.9% (placebo group), was administered. Ropivacaine, 0.2%, was started 6 h after the initial block through the interscalene catheter for 48 h (t48) in all patients. At t0, the patient received either 5 ml/h ropivacaine, 0.2% (ropivacaine group), or 5 ml/h NaCl, 0.9% (placebo group), for 48 h through the IC catheter. All patients received an intravenous morphine patient-controlled analgesia device. Pain scores at the shoulder and at the IC donor site were assessed at rest and during motion every 8 h for 48 h and after 3 months. Plasma concentrations of total and unbound ropivacaine, morphine consumption, and patient satisfaction were assessed.
At the IC donor site, pain was significantly lower in the ropivacaine group compared with the placebo group at rest and during motion at any time. Total and unbound plasma concentrations of ropivacaine were below the toxic threshold in both groups. Morphine consumption was significantly lower in the ropivacaine group after 24 and 48 h. Patient satisfaction was significantly higher in the ropivacaine group. At 3 months, pain at the IC during motion was significantly lower in the ropivacaine group.
Continuous application of 0.2% ropivacaine through an IC catheter after Bankart repair with IC bone grafting is an effective method for pain relief for the first 48 h, with few adverse effects and high patient satisfaction. The benefit of this technique is still present after 3 months.
Autogenous iliac crest bone is the gold-standard graft for spinal fusion surgery. Unfortunately, there is a frequent incidence of graft site pain that persists well into the postoperative period with complication rates reported in 2.8-39% of patients. Persistent pain lasting at least 2 years is reported in 15-39% of patients.
The objective of this work was to determine the incidence of acute and persistent pain as well as patient assessment of graft site appearance following iliac crest bone graft harvest for anterior lumbar interbody fusion (ALIF). The control arms of four randomized prospective multicenter clinical trials evaluating recombinant human bone morphogenetic protein-2 (rhBMP-2) versus autogenous iliac crest bone graft were combined. Two hundred eight patients underwent iliac crest bone graft harvest for ALIF in threaded cylindrical cages or threaded bone dowels. Patients were assessed at each postoperative visit with questionnaires evaluating graft site pain intensity, duration, and appearance.
Two hundred eight patients underwent iliac crest bone graft harvest for ALIF as the control group of four randomized prospective multicenter clinical trials evaluating rhBMP-2 versus autogenous iliac crest bone graft in threaded cylindrical cages or threaded bone dowels. Most patients in the control group had anterior iliac crest graft harvest, equally from the right and left side. Three grafts (1.4%) were taken from the posterior crest and six (2.9%) were tricortical. Follow-up was obtained at hospital discharge, 6 weeks, 3, 6, 12, and 24 months. A pain evaluation score was made up of two Visual Analog Scales: one scale measuring intensity, the other frequency of pain. For the intensity scale, a rating of "0" meant no pain and "10" was "as bad as it could be." For the frequency scale, a rating of "0" meant pain was present "none of the time" and "10" meant it was present "all the time." Combining these scales, a total score of 20 indicated the worst pain was present all the time. Patients were also questioned about the graft site appearance.
Two hundred eight patients underwent iliac crest harvest, and prospective data were available on 202 patients. At hospital discharge, 2 patients (1%) had no pain; this increased to 34 of 199 (17%) at 6 weeks postoperatively and to 85 of 199 patients (43%) at 3 months. However, 41% of patients reported pain at 6 months postoperatively (79/192), and 33% of 168 reported pain at 1 year. One hundred forty-one of 208 patients completed a survey at 24 months, with 31% reporting some level of pain. At hospital discharge, the graft site pain score ranged from 0 to 20 with a mean of 12.8, decreasing to 7.3 at 6 weeks, to 3.8 at 3 months, and to 2.9, 2.4, and 1.8 at 6, 12, and 24 months, respectively. At all time intervals, P values from t tests comparing the mean with 0 were <0.001. Graft site appearance at discharge was good in 49% of patients, fair in 40%, and poor in 11%. At 6 weeks, appearance was good in 69%, fair in 27%, and poor in 5%; at 3 months, it was good in 75%, fair in 24%, and poor in 2%; at 6 months, it was good in 82%, fair in 15%, and poor in 3%; at 12 months, it was good in 82% and fair or poor in 19%; and at 24 months, it was good in 84% and fair or poor in 16%. There was no significant difference between posterior and anterior harvest sites or bicortical grafts, and all were included in the analysis. Right or left side demonstrated no differences.
This is the first study known to the authors presenting results of prospective data collected in a multicenter study evaluating iliac crest harvest site pain, both intensity and frequency, as well as graft site appearance. The results demonstrate that 31% of patients had persistent pain at 24 months postoperatively and 16% reported fair or poor appearance of their graft site.
Persistent donor site pain remains a problem with harvest of autogenous iliac crest bone graft for spinal fusion. This prospective study, the first such study reported for ALIF, confirms that donor site pain remains a significant postoperative management problem.
Substitutes for bone graft have been advocated to avoid the potential morbidity associated with harvest of autogenous iliac crest graft. However, no current commercially available graft equals autogenous bone's osteoinductive and osteoconductive qualities. We reviewed our patients' morbidity after harvest of anterior iliac crest bone grafts for procedures involving the foot and ankle.
A computerized analysis of patient records was undertaken to identify all patients who had a harvest of unicortical iliac crest bone graft during a 12-year period. Patients were contacted either by telephone or by mailed questionnaire, inquiring about the postoperative morbidity of the procedure. Medical records were reviewed for any related complications.
Of the 169 patients identified, 134 could be contacted. Follow-up ranged from 1 to 13 years. Not all patients answered every question. At latest follow up, 120 (90%)-patients reported no pain at the bone graft site. Eleven patients complained of persistent residual numbness lateral to the harvest site on the pelvis. Of these 120 patients, 32 (27%) reported that pain at the graft site was greater than the pain at the operative site during the initial postoperative period. No patients had extra hospital days as a result of the bone graft harvest. No deep infections occurred, although 12 (6.7%) of 180 patients had a postoperative hematoma or seroma. Overall, 116 (90%) of 129 patients were satisfied or very satisfied with their bone graft harvest.
Harvesting of autogenous iliac crest bone graft provides the optimal bone graft material, yields minimal morbidity, and is an acceptable choice in supplementing surgical procedures on the foot and ankle.
The choice of local anaesthetic is influenced by several factors; it must provide effective anaesthesia and analgesia for the duration of the procedure and meet the expectations for post-operative pain management. Of primary concern is patient safety. Bupivacaine, currently the most widely used long acting local anaesthetic agent in both surgery and obstetrics, generally has a good safety record but its use has resulted in fatal cardiotoxicity, usually after accidental intravascular injection. Hence, for several years there has been a need for a long acting local anaesthetic, similar to bupivacaine, but with an improved cardiovascular safety profile. Levobupivacaine, the single enantiomer version of bupivacaine, offers a new long acting local anaesthetic, clinically equivalent in anaesthetic potency to bupivacaine, but with a reduced toxicity profile. Preclinical studies, from in vitro in single ion channels to whole large animal models, have unquestionably demonstrated that levobupivacaine is significantly less CNS toxic and cardiotoxic than bupivacaine. Cardiotoxicity is less easy to study in man, as the clinical signs are not usually seen until the CNS toxicity is marked, and well beyond that which is tolerable to volunteers or patients. Nevertheless, levobupivacaine has been shown to have less effect on myocardial contractility and QTc prolongation, early signs of cardiotoxicity, than bupivacaine in healthy subjects. In clinical use levobupivacaine has been shown to be equally efficacious as bupivacaine at comparable doses and concentrations, and has been found to produce similar anaesthetic characteristics (onset, duration and density of block). As levobupivacaine now becomes commercially available, the database available with which to make efficacy and safety comparisons with other local anaesthetics will increase, and the true value of this new long acting local anaesthetic should become even more apparent.
A substantial number of patients report persistent pain after graft harvest from the anterior iliac crest. There have been several retrospective case series published that suggest that iliac crest reconstruction using a variety of techniques may decrease graft site pain. This study, a randomized, controlled clinical trial at a university hospital, tested the hypothesis that reconstruction of the iliac crest will reduce graft harvest site pain.
A randomized, controlled clinical trial using the McGill Pain Inventory as the primary outcome measure was performed to evaluate the effect of anterior iliac crest reconstruction after graft harvest. Thirty patients who were treated with anterior cervical discectomy and fusion or cervical corpectomy and fusion with autologous iliac crest graft were randomized to one of two groups. Patients in Group 1 were treated with reconstruction of the iliac crest with commercially available tricalcium phosphate bone void filler after graft harvest. Patients in Group 2 were treated without graft site reconstruction. Graft site pain was assessed immediately after surgery, 6 weeks after surgery, and 3 months after surgery.
Treatment groups were well matched with regard to patient age, sex, and smoking history. Although patients in each group reported persistent pain 6 weeks and 3 months after graft harvest, patients in the reconstruction group reported significantly less severe pain at 6 weeks and tended to have less pain at 3 months after surgery.
Reconstruction of the iliac crest with tricalcium phosphate bone void filler significantly decreases the severity of postoperative pain 6 weeks after surgery.
Parallel design, prospective, double-blind, randomized, controlled trial composed of two independent groups treated with a continuous infusion catheter (saline vs. Marcaine) placed into the iliac crest bone graft (ICBG) site.
To determine the effects of postoperative continuous local anesthetic agent infusion at the ICBG harvest site in reducing pain, narcotic demand and usage, and improving early postoperative function after spinal fusion.
Harvesting iliac crest bone has been shown to be a source of pain and morbidity. Long-term patient complaints may be more closely associated with the procurement of the iliac crest graft rather than the primary surgical site.
Thirty-seven patients were enrolled in a prospective, randomized, double-blind parallel-designed study after informed consent and IRB approval was obtained. Twenty-eight patients had ICBG harvested for lumbar arthrodesis and nine for cervical arthrodesis. During spinal arthrodesis surgery, patients were randomly assigned to receive 96 mL (2 mL/hr x 48 hours) of either normal saline (control group, n = 22) or 0.5% Marcaine (treatment group, n = 15) delivered via a continuous infusion catheter placed at the ICBG harvest site. All patients received Dilaudid PCA after surgery. Pain scores, narcotic use/frequency, activity level, and length of stay (LOS) were recorded. Physicians, patients, nursing staff, and statisticians were blinded to the treatment.
Mean patient age was 60 years and similar between groups. Narcotic dosage, demand frequency, and mean VAS pain score were significantly less in the treatment (Marcaine) group at 24 and 48 hours (P < 0.05). The average LOS was 4.1 days with no difference between Marcaine or control groups. No complications were attributed to the infusion-catheter system.
Continuous infusion of 0.5% Marcaine at the ICBG harvest site reduced postoperative parenteral narcotic usage by 50% and decreased overall pain scores. No complications were attributed to the infusion-catheter system. The use of continuous local anesthetic infusion at the iliac crest may help in alleviating acute graft-related pain, hastening patient recovery and improving short-term satisfaction.
To assess the benefits in terms of reductions in the risks of deep vein thrombosis (DVT) and of pulmonary embolism (PE), and hazards in terms of major bleeding, of: (i) mechanical compression; (ii) oral anticoagulants; (iii) dextran; and (iv) regional anaesthesia (as an alternative to general anaesthesia) in surgical and medical patients.
Electronic databases, search of Antithrombotic Trialists' Collaboration database, contact with trialists and manufacturers.
All trials identified as fitting the selection criteria were independently assessed. The primary outcomes were DVT, PE and major bleeding events, and proximal venous thrombosis (PVT) and fatal PE were secondary outcomes. Trials were subdivided into those that had assessed a method as the only means of thromboprophylaxis ('monotherapy') and those that had assessed the effects of adding a method to another form of thromboprophylaxis ('adjunctive therapy').
Mechanical compression methods reduced the risk of DVT by about two-thirds when used as monotherapy and by about half when added to a pharmacological method. These benefits were similar irrespective of the particular method used (graduated compression stockings, intermittent pneumatic compression or footpumps) and were similar in each of the surgical groups studied. Mechanical methods reduced the risk of PVT by about half and the risk of PE by two-fifths. Oral anticoagulants, when used as monotherapy, reduced the risk of DVT and of PVT by about half, and this protective effect appeared similar in each of the surgical groups studied. There was an apparently large four-fifths reduction in the role of PE, but not only was the magnitude of this reduction statistically uncertain, but also pulmonary embolism was reported by a minority of trials, so it may be subject to selection bias. Oral anticoagulant regimens approximately doubled the risk of major bleeding and appeared less effective at preventing DVT than heparin regimens, although were associated with less major bleeding. Dextran reduced the risk of DVT and of PVT by about half, again irrespective of the type of surgery, but too few studies had reported PE to provide reliable estimates of effect on this outcome. Dextran appeared to be less effective at preventing DVT than the heparin regimens studied. Dextran was associated with an increased risk of bleeding, but too few bleeds had occurred for the size of this excess risk to be estimated reliably. Compared with general anaesthesia, regional anaesthesia reduced the risk of DVT by about half, and this benefit appeared similar in each of the surgical settings studied. Regional anaesthesia was associated with less major bleeding than general anaesthesia.
In the absence of a clear contraindication (such as severe peripheral arterial disease), patients undergoing a surgical procedure would be expected to derive net benefit from a mechanical compression method of thromboprophylaxis (such as graduated compression stockings), irrespective of their absolute risk of venous thromboembolism. Patients who are considered to be at particularly high risk of venous thromboembolism may also benefit from a pharmacological thromboprophylactic agent, but since oral anticoagulant and dextran regimens appear less effective at preventing DVT than standard low-dose unfractionated heparin or low molecular weight heparin regimens, they may be less suitable for patients at high risk of venous thromboembolism, even though they are associated with less bleeding. Whenever feasible, the use of regional anaesthesia as an alternative to general anaesthesia may also provide additional protection against venous thromboembolism. There is little information on the prevention of venous thromboembolism among high-risk medical patients (such as those with stroke), so further randomised trials in this area would be helpful.
Ropivacaine (Naropin) is the pure S(-)-enantiomer of propivacaine, and is a long-acting amide local anaesthetic agent, eliciting nerve block via reversible inhibition of sodium ion influx in nerve fibres. Ropivacaine is a well tolerated regional anaesthetic effective for surgical anaesthesia as well as the relief of postoperative and labour pain. The efficacy of ropivacaine is similar to that of bupivacaine and levobupivacaine for peripheral nerve blocks and, although it may be slightly less potent than bupivacaine when administered epidurally or intrathecally, equi-effective doses have been established. Clinically adequate doses of ropivacaine appear to be associated with a lower incidence or grade of motor block than bupivacaine. Thus ropivacaine, with its efficacy, lower propensity for motor block and reduced potential for CNS toxicity and cardiotoxicity, appears to be an important option for regional anaesthesia and for the management of postoperative and labour pain.
More than 2 million people undergo major orthopedic surgery each year, and this rate is expected to continue rising as our population ages. Our patients are at particularly high risk for deep vein thrombosis (DVT) and pulmonary embolism. The latest guidelines from the American College of Chest Physicians recommend thromboprophylaxis for high-risk orthopedic surgery patients. Although specific recommendations vary by type of surgery, low-molecular-weight heparin, fondaparinux, warfarin, and sometimes low-dose unfractionated heparin are effective alone or with mechanical prophylaxis. Goals of treatment are to prevent proximal and distal DVT, pulmonary death, chronic pulmonary hypertension, and postthrombotic syndrome.
Iliac crest bone harvest donor site morbidity: A statistical evaluation
- Jc Banwart
- Ma Asher
- Rs Hassanein
Banwart JC, Asher MA, Hassanein RS. Iliac crest bone harvest
donor site morbidity: A statistical evaluation. Spine 1995;20(9):
1055–60.
Levobupivacaine: a new safer long acting local anaesthetic agent
- R W Gristwood
- J L Greeves
Gristwood RW, Greeves JL. Levobupivacaine: a new safer long
acting local anaesthetic agent. Expert Opin Invest Drugs 1999;
8(6):861-76.
Donor site morbidity of the anterior iliac crest following cancellous bone harvest
- Beirne
Iliac crest bone harvest donor site morbidity: A statistical evaluation
- Banwart