The management of long bone infected non-unions; posttraumatic chronic osteomyelitis and primary segmental bone defects constitute some of the most difficult reconstructive challenges encountered by orthopaedic surgeons. Measures employed to treat these conditions are tantamount to limb salvage with amputation a likely outcome if reconstructive endeavors prove unsuccessful. The Ilizarov method of distraction osteogenesis and bone transport, following radical debridement in the case of infection, is one potential management option in such cases. Aim: To assess outcome in a cohort of patients with long bone defects treated with this technique. Methods: Clinical review coupled with retrospective chart study and radiographic assessment. Results: 24 patients (20 adults, 4 children) underwent treatment over a 6-year period. 21 had defects of a primary traumatic aetiology (18 tibial and 3 femoral fractures). The mean interval between injury and commencing bone transport was 41.6 months. The mean defect dimension requiring transport was 9cm (range 4.5 to 28cm). The mean external fixation time was 14.6 months. Union occurred in 21 cases. Autologous bone grafting of the docking site was performed in 6 cases in order to stimulate union. Following removal, frames were reapplied in 4 cases due to refracture or development of angular deformity. Two patients proceeded to below knee amputations. According to ASAMI* criteria, the bone result was excellent in 12 patients, good in 5 patients, fair in one patient and poor in 6 patients. Functional outcome was excellent in 7 patients, good in 12, fair in 2 and poor in 3. Conclusion: The Ilizarov method of bone transport is a reliable procedure providing consistent results in complex cases when frequently alternative treatment options have been exhausted. Outcome compares favorably with other treatment modalities such as vascularised free tissue transfer or Papineau type grafting procedures. The treatment period is lengthy and both major and minor complications are common but limb salvage is successful in the main part. More aggressive treatment and appropriate fracture management in the early stages may have a role to play in improving the prognosis of these patients. *Association for the Study and Application of the Methods of Ilizarov
OBJECTIVE: To assess whether a superior hypogastric plexus block performed during laparoscopic hysterectomy reduces postoperative pain. METHODS: We conducted a multicenter, randomized, single-blind, controlled trial of superior hypogastric plexus block at the start of laparoscopic hysterectomy. Women undergoing a laparoscopic hysterectomy for any indication and with any other concomitant laparoscopic procedure were eligible. Standardized preoperative medications and incisional analgesia were provided to all patients. Our primary outcome was the proportion of patients with a mean visual analog scale (VAS) pain score lower than 4 within 2 hours postoperatively. Patients but not surgeons were blinded to the treatment group. Twenty-nine patients per group was estimated to be sufficient to detect a 38% absolute difference in the proportion of patients with a VAS score lower than 4 at 2 hours postoperatively, with 80% power and an α of 0.05. To account for loss to follow-up and potential imbalances in patient characteristics, we planned to enroll 50 patients per group. All analyses were intention to treat. RESULTS: Between January 2018 and February 2019, 186 patients were eligible; 100 were randomized and analyzed. Demographic and clinical characteristics were similar between the two groups. There was no significant difference in the proportion of patients with a mean VAS score lower than 4 within 2 hours postoperatively between patients who received a superior hypogastric plexus block (57%) and patients who did not (43%) (odds ratio 1.63, 95% CI 0.74–3.59; adjusted odds ratio 1.84, 95% CI 0.75–4.51). CONCLUSION: Among patients undergoing laparoscopic hysterectomy with standardized enhanced perioperative recovery pathways, superior hypogastric plexus block did not significantly reduce postoperative pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03283436.
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