Partial hand replantation using free microsurgical replantation with staged heterotopic banking of amputated parts: towards improving long term outcomes

In hand trauma, the uninjured forearm has been touted as the ideal site for ectopic banking in digit/hand amputations. Here, we describe the temporary ectopic implantation and subsequent replantation of a partially amputated hand and highlight the "Three R's" - Recovery, Rehabilitation, and Revision over the first year of recovery.

Pain Control after Reduction Mammaplasty with Combination Bupivacaine and Dexamethasone Regional Block: A Randomized Controlled Trial

BACKGROUND

There are many approaches to pain control in reduction mammaplasty. Preoperative bupivacaine regional blocks control pain relatively inexpensively ($0.07/mL), but last only 8 hours. A liposomal bupivacaine formulation lasts 72 hours but can be costly ($17.21/mL). Orthopedic and thoracic operations have demonstrated that dexamethasone ($0.44/mL) plus bupivacaine can prolong analgesia. The authors conducted a double-blind, randomized, controlled trial to determine whether dexamethasone plus bupivacaine regional block improves postoperative pain control, reduces inpatient narcotic use, and improves patient satisfaction.

METHODS

Female patients were randomized into control and experimental groups. Both groups received preoperative modified block of the pectoral nerves: bupivacaine plus saline (control group) or bupivacaine plus dexamethasone (experimental group). Postoperative pain regimens were standardized. Vital signs, pain scores, narcotic consumption, and antiemetic use were recorded throughout the hospitalization. Quality-of-life surveys were distributed at the first postoperative visit.

RESULTS

Fifty-one patients completed the study: 25 control and 26 experimental group patients. The experimental group averaged lower pain scores, although there was no statistically significant difference overall or at each 4-hour interval. Postoperative narcotic use was significantly lower in the experimental group (mean, 23.2 oral morphine equivalents versus 36.6 oral morphine equivalents per patient; P = 0.026). There were no differences in 4-hour interval vital signs, antiemetic use, or length of stay. Survey results showed enhanced quality of life in the experimental group, but this was not statistically significant.

CONCLUSIONS

The addition of dexamethasone to bupivacaine in the preoperative modified block of the pectoral nerves block before bilateral reduction mammaplasty resulted in significantly less narcotic consumption in the hospital. This can be a cost-effective adjunct for postoperative pain control.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.