[Comparison of adductor canal block for analgesia in arthroscopic surgery with ropivacaine alone and ropivacaine and clonidine]

BACKGROUND AND OBJECTIVES

Inadequate pain relief after anterior cruciate ligament reconstruction affects mobility leading to development of adhesions, weakened ligament insertion and muscle atrophy. Adductor canal block for postoperative analgesia preserves quadriceps strength. The present study was conducted to compare pain free period in patients undergoing arthroscopic anterior cruciate ligament reconstruction, receiving ultrasound-guided adductor canal block with ropivacaine alone and ropivacaine with clonidine.

METHODS

A prospective randomized double blinded study was conducted including sixty-three adult, ASA class I, II patients undergoing anterior cruciate ligament reconstruction. They were randomized into three groups: Group S - control group received adductor canal block with 30mL saline, Group R - ropivacaine group received adductor canal block with 30mL of 0.375% ropivacaine and Group RC - clonidine group received adductor canal block with 30mL of 0.375% ropivacaine with clonidine 1μg.kg^-1. The primary aim was to compare the pain free period in patients receiving adductor canal block with ropivacaine alone or ropivacine with clonidine. The secondary outcomes were pain score at rest and movement, total analgesic requirement, sedation score and postoperative nausea and vomiting.

RESULTS

The mean pain free periods were 20min, 384.76min and 558.09min for Group S, Group R and Group RC, respectively and this difference was statistically significant (p < 0.001). There was no significant difference between Group R and Group RC in terms of pain scores at rest and movement and total analgesic requirement.

CONCLUSION

Addition of clonidine to ropivacaine in USG guided adductor canal block led to significant prolongation of pain free period though pain score at rest and movement, and rescue analgesic requirement, did not differ.

Bleeding during percutaneous dilatational tracheostomy - What to do while waiting for the surgeon?

A patient suffered significant bleeding during an attempt at percutaneous dilatational tracheostomy due to an aberrant anterior jugular vein. Bleeding was controlled with pressure temporarily, but quickly returned necessitating conversion to an open technique. We present an algorithm for the management of significant peri-procedural bleeding during this procedure.

Epidemiological profile of sports-related knee injuries in northern India: An observational study at a tertiary care centre

BACKGROUND

Sports-related knee injuries occur commonly in athletes. However, there is no published epidemiological study from India till date.

OBJECTIVES

The purpose of this study was to identify common injuries sustained by Indian athletes participating in different sports and to study various associated demographic features. A secondary objective was to investigate different factors, which may affect return to sport by the athlete.

STUDY DESIGN

Cross-sectional study (observational study).

STUDY CENTRE

Sports injury clinic, PGIMER, Chandigarh.

METHODS

Out of 465 athletes who presented to us with sports-related knee injuries over a 5-year period, 363 athletes (from 24 different sports) with complete records were identified. Data were analysed for demographic features, type of sport, mechanism of injury, injury scenario, athlete's level of play, injury duration at presentation, injury patterns and type of management. Telephonic interviews were conducted with each athlete to enquire about return to sport and time lost in sport due to the knee injury. Factors associated with return to sport were investigated using statistical tests of association.

RESULTS

Soccer was found to be the most common sport associated with knee injuries accounting for 30.6% of the injuries followed by kabaddi (20.9%). The most common mechanism was non-contact injury (64.4%). Competitive injuries were found to be significantly more than practice/training injuries (p < 0.0001). The most common injuries noted were ACL tears (n = 314) followed by meniscus injuries (n = 284) and the most common combination of injuries were an ACL tear with medial meniscus tear (n = 163). Only 39.8% of the athletes returned to sport. Mean duration of time lost in sport among those who returned to sport was 8.84 months. Return to sport was significantly associated with body mass index, level of competitiveness of the athlete and type of management (p = 0.017, 0.045 and <0.0001, respectively).

CONCLUSION

Knee injuries take a huge toll on an athlete's career as observed in this study. Prevention of knee injuries is of paramount importance and more focussed epidemiological studies are needed for formulating policies to prevent sports injuries in both professional and amateur athletes.

LEVEL OF EVIDENCE

IV.

Drill bit failure and retrieval during arthroscopic ACL reconstruction

A case of broken drill bit during arthroscopic ACL reconstruction and the technique adopted to overcome this complication is presented. We also review the literature for intra-operative incidents and technical complications during arthroscopic ACL reconstruction and various precautions we should implement to prevent such technical pitfalls from coming into reality.

The Avon patellofemoral joint replacement: Five-year results from an independent centre

Between May 1998 and May 2007 we carried out 50 Avon patellofemoral joint replacements in 32 patients with isolated patellofemoral osteoarthritis. There were no revisions in the first five years, giving a cumulative survival of 100% for those with a minimum follow-up of five years. The mean follow-up was 5.3 years (2.1 to 10.2). The median Oxford knee score was 30.5 (interquartile range 22.25 to 42.25). In patients with bilateral replacements the median Euroqol General health score was 50 which was significantly lower than that of 75 in those with a unilateral replacement (p = 0.047). The main complication was progression of disease, which was identified radiologically in 11 knees (22%). This highlights the need for accurate selection of patients. Our findings suggest that the Avon prosthesis survives well and gives a satisfactory functional outcome in the medium term.

Calcific myonecrosis: a report of ten new cases with an emphasis on MR imaging

The aim of this study is to report the typical radiographic and MR imaging features of calcific myonecrosis, which help to distinguish this rare entity from other causes of a calcifying calf mass. Ten patients with a final diagnosis of calcific myonecrosis were referred to a specialist orthopaedic oncology service in a 5-year period with the presumptive diagnosis of malignancy based on recent clinical presentation and imaging findings. Radiographs were available for retrospective review in all ten cases and MR imaging in six. All patients presented with a slow-growing painless calf mass. All gave a history of major trauma to the lower leg many years before, but in only two cases did the referring clinician query whether trauma might be a contributory factor. Radiographs showed well-defined fusiform mineralised masses up to 25 cm in length arising within the calf. The calcification was consistently peripheral and plaque-like. Ossification was not present. MR imaging showed the anterior compartment to be involved in four cases and all compartments in two. T1- and T2-weighted images showed peripheral low signal intensity, more prominent on the T2-weighted images, because of the peripheral mineralization. The contents of the masses were variable on T1-weighted images depending on the differing amounts of blood breakdown products and were heterogeneous on T2-weighted images. The latter may be explained by a combination of the mineralisation and T2 shortening due to blood breakdown products. A gadolinium chelate, administered in two cases, failed to show any appreciable enhancement. Calcific myonecrosis has characteristic clinical, radiographic and MR features that should make the condition easy to recognise. Despite its rarity, it should be included in the differential diagnosis of focal mineralisation of the calf.

Citric acid demineralization of cementum and dentin: the effect of application pressure

Previous work has shown that a 25-30% citric acid solution was the most effective concentration with which to demineralize dentin. The purpose of this investigation was to study the topography, using a scanning electron microscope, of root surfaces treated with a 30% citric acid solution using various application pressures. 20 freshly extracted human teeth were collected and stored in physiologic saline at room temperature. 3 root specimens, approximately 3x5x5 mm in size, were prepared from the coronal periodontally healthy area of each tooth. 30 specimens were root planed to expose dentin (dentin group) while the remaining 30 specimens were lightly scaled to remove periodontal soft tissue (cementum group). A freshly made 30% citric acid (CA) solution, (pH = 1.60), was applied to each of the experimental areas. Cotton pellets soaked in the citric acid solution were either placed (CAP), lightly rubbed (CAR) or heavily burnished (CAB) on the prepared root surface for 3 min. Pellets were resoaked every 30 s. The root sections were rinsed, fixed in glutaraldehyde, dehydrated in graded ethanol, critically point dried in liquid CO2 and sputter coated in gold. The treated surfaces were assessed for fibril tufting using scanning electron microscopy. Assessment was made of: (i) the % of surface area tufted; (ii) tufting depth (0-3); (iii) tufting density (1-3). Results of the study showed significantly more tufted surface area and greater tufting depth on both dentin and cementum for CAR and CAB compared to CAP. CAP produced a flat/mat fibril surface with no evidence of tufting.(ABSTRACT TRUNCATED AT 250 WORDS)

The versatility of the contoured AO plate as a mode of fixation for proximal femoral fractures

Proximal femoral fractures, especially in young adults, usually are high-energy injuries associated with severe comminution. Presently available fixation devices such as the blade plate and DHS are difficult to apply in comminuted cases, their application requires the use of an image intensifier, and their versatility is limited. This report describes the use of the AO plate molded according to the proximal femoral anatomy in 21 cases (seven subtrochanteric and 14 trochanteric fractures) in which high-energy injuries were sustained. Eleven cases were primarily bone grafted. Postoperative mobilization was started by an average of 5.4 weeks. All cases united by an average of 3.2 months. There were six excellent, ten good, three fair, and one poor result (one patient died). This method was found to be superior to conventional devices as it offers more versatility in placement of screws and plate contouring. The inventory of implants is also reduced, and there is no need for specialized instruments, a significant factor in Third World countries.

Mapping human T cell epitopes on phospholipase A2: the major bee-venom allergen

Phospholipase A2 (PLA2), the major bee-venom allergen, was purified by gel filtration, inactivated by denaturing, and carboxymethylating its cysteine residues. Peripheral blood mononuclear cells from an individual (HLA-DR2 [15], Dw52, DQ1 and DQ3) allergic to bee stings were used to generate cell lines specific for PLA2 and a control antigen, tetanus toxoid. These lines were 90% CD3+, 64% CD4+ and 20% CD8+ by fluorocytometry analysis. T-lymphocyte epitope mapping done with 12 overlapping synthetic peptides of PLA2 revealed two immunodominant epitopes. These epitopes correspond to amino acid sequences 50 to 69 and 83 to 97 of PLA2. Cytokine interleukin-4 and Interferon-gamma secretion was studied from PLA2- and tetanus toxoid-specific cell lines. Interleukin-4 secretion was common to both cell lines but only tetanus-toxoid cell lines secreted interferon-gamma. No interferon-gamma was found to be secreted by PLA2-specific cell line in response to stimulation by PLA2 or the two immunodominant peptides.

Current status of mold immunotherapy

There is evidence to suggest that molds can cause IgE-mediated upper respiratory tract disorders and immunotherapy is efficacious in a select group. The environmental sampling studies show a remarkably small numbers of molds accounting for a majority of the mold load in various diverse locations. These are Cladosporium, Basidiospores, Aspergillus, and Alternaria-Penicillin families. Basidiospores have been underreported in the older studies because of difficulties in their identification. Whether the absolute mold level is the most important factor leading to IgE formation and induction of upper respiratory tract symptoms is uncertain. Certainly, the majority of the studies are based on the assumption that the absolute level of mold in the environment is the most important factor leading to the development of symptoms, but this is not based on strong evidence. A major problem in the majority of the studies is a lack of standardization of extracts which may lead to false negatives on skin testing and thus produce variable data in population evaluations comparing the prevalence of mold to its ability to induce IgE production and symptoms. The best current trials to document the efficacy of mold immunotherapy have been with the standardized Cladosporium extract. Unfortunately, these results cannot be extrapolated to the commercially available mold extracts available in the United States either for immunotherapy or for skin testing. These extracts are highly variable in their potency, prone to high false negative rates, and at best serve as poor skin testing reagents and possibly even worse immunotherapy reagents. Adequately standardized mold reagents are urgently needed to determine whether the Cladosporium data can be extrapolated to them in any meaningful way.

Socialization, locus of control, and dogmatism as related to counsellors' office settings

Psychologists and social workers in geographically decentralized and sometimes isolated settings must often work autonomously and make independent decisions. It was predicted that staff who choose to work in these settings would be more internally directed and more dogmatic than staff who worked in a centralized office. Decentralized staff were also hypothesized to want less control by others and less social inclusion. On Rotter's (1966) Internal-External Scale, Rokeach's (1959) Dogmatism Scale and Shurz's FIRO-B measures for 29 social workers and psychologists there were differences on the FIRO-B but not in internality or dogmatism. The results are discussed in terms of the sample's characteristics and the implications for the decentralization of counselling services.