Evidence‐based management of pain after laparoscopic cholecystectomy: a PROSPECT review update EULAR recommendations for the management of knee osteoarthritis: report of a task force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT) Comparison of Perioperative Oral Multimodal Analgesia Versus IV PCA for Spine Surgery Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. Implant positioning in TKA: comparison between conventional and patient-specific instrumentation. Patient-Specific CT-Based Instrumentation versus Conventional Instrumentation in Total Knee Arthroplasty: A Prospective Randomized Controlled Study on Clinical Outcomes and In-Hospital Data Individuals’ experience of living with osteoarthritis of the knee and perceptions of total knee arthroplasty IV Acetaminophen: Efficacy of a Single Dose for Postoperative Pain After Hip Arthroplasty Subset Data Analysis of 2 Unpublished Randomized Clinical Trials Evidence-based postoperative pain management in nursing: is a randomized-controlled trial the most appropriate design? Comparison of Mini-Midvastus and Conventional Total Knee Arthroplasty with Clinical and Radiographic Evaluation: A Prospective Randomized Clinical Trial with 5-Year Follow-up. Safety and Efficacy of Acupuncture in Children: A Review of the Evidence Effect of a patient blood management programme on preoperative anaemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle. Fast-track hip and knee replacement — what are the issues? The American Heart Association's recommendations for expanding the applications of existing and future clinical registries: a policy statement from the American Heart Association. [Prospective and comparative study of minimally invasive posterior approach versus standard posterior approach in total hip replacement]. Local infiltration anesthesia with steroids in total knee arthroplasty: A systematic review of randomized control trials. Myocardial infarction following fast-track total hip and knee arthroplasty—incidence, time course, and risk factors: a prospective cohort study of 24,862 procedures Patellar Resurfacing in Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Study with Five to Seven Years of Follow-up Resurfacing of the Patella in Total Knee Arthroplasty. A Prospective, Randomized, Double-Blind Study* Complementary therapies and integrative medicine in lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Development of a research-based standard for assessment, intervention, and evaluation of pain after neonatal and pediatric cardiac surgery. The future of fast‐track surgery Mixed adherence to clinical practice guidelines for colorectal cancer in the Southern Netherlands in 2002.
Background : Significant pain can be experienced after laparoscopic cholecystectomy . This systematic review aims to formulate PROSPECT ( PROcedure SPECific Postoperative Pain ManagemenT ) recommendations to reduce postoperative pain after laparoscopic cholecystectomy . Methods : R and omised controlled trials published in the English language from January 2006 ( date of last PROSPECT review ) to December 2017 , assessing analgesic , anaesthetic , or operative interventions for laparoscopic cholecystectomy in adults , and reporting pain scores , were retrieved from MEDLINE and Cochrane data bases using PRISMA ( Preferred Reporting Items for Systematic Review s and Meta‐Analyses ) search protocol s. PROSPECT methodology was used , and recommendations were formulated after review and discussion by the PROSPECT group ( an international group of leading pain specialists and surgeons ) . Results : Of 1988 r and omised controlled trials identified , 258 met the inclusion criteria and were included in this review . The studies were of mixed method ological quality , and quantitative analysis was not performed because of heterogeneous study design and how outcomes were reported . Conclusions : We recommend basic analgesic techniques : paracetamol + NSAID or cyclooxygenase‐2 specific inhibitor + surgical site local anaesthetic infiltration . Paracetamol and NSAID should be started before or during operation with dexamethasone ( GRADE A ) . Opioid should be reserved for rescue analgesia only ( GRADE B ) . Gabapentanoids , intraperitoneal local anaesthetic  , and  transversus abdominis plane blocks  are not recommended ( GRADE D ) unless basic analgesia is not possible . Surgically , we recommend low‐pressure pneumoperitoneum , postprocedure saline lavage , and aspiration of pneumoperitoneum ( GRADE A ) . Single‐port incision techniques are not recommended to reduce pain ( GRADE A ) BACKGROUND Osteoarthritis ( OA ) is the most common joint disease encountered throughout Europe . A task force for the EULAR St and ing Committee for Clinical Trials met in 1998 to determine the method ological and logistical approach required for the development of evidence based guidelines for treatment of knee OA . The guidelines were restricted to cover all currently available treatments for knee OA diagnosed either clinical ly and /or radiographically affecting any compartment of the knee . METHODS The first stage was the selection of treatment modalities to be considered . The second stage comprised a search of the electronic data bases Medline and Embase using a combination of subject headings and keywords . All European language publications in the form of systematic review s , meta-analyses , r and omised controlled trials , controlled trials , and observational studies were included . During stage three all the relevant studies were quality scored . The summary statistics for vali date d outcome measures , when available , were recorded and , where practical , the numbers needed to treat and the effect size for each treatment were calculated . In the fourth stage key clinical propositions were determined by expert consensus employing a Delphi approach . The final stage ranked these propositions according to the available evidence . A second set of propositions relating to a future research agenda was determined by expert consensus using a Delphi approach . RESULTS Over 2400 English language publications and 400 non-English language publications were identified . Seven hundred and forty four studies presented outcome data of the effects of specific treatments on knee OA . Quantitative analysis of treatment effect was possible in only 61 studies . Recommendations for the management of knee OA based on currently available data and expert opinion are presented . Proposals for a future research agenda are highlighted . CONCLUSIONS These are the first clinical guidelines on knee OA to combine an evidence based approach and a consensus approach across a wide range of treatment modalities . It is apparent that certain clinical propositions are supported by substantial research based evidence , while others are not . There is thus an urgent need for future well design ed trials to consider key clinical questions Study Design A preintervention and postintervention design was used to examine a total of 200 patients . Objective After successful implementation at our institution of a perioperative oral multimodal analgesia protocol in major joint arthroplasty , a modified regimen was provided to patients undergoing spine procedures . Summary of Background Data A proactive , multimodal approach is currently recommended for the management of acute postoperative pain . Inadequate postoperative analgesia can negatively influence surgical outcome and duration of rehabilitation . Routine use of intravenous patient controlled analgesia ( IV PCA ) after surgery can result in substantial functional interference , side effects , and lead to untoward events as a result of programming errors . Methods A preintervention and postintervention design was used to compare a  historical control group of spine surgery patients who received conventional IV PCA ( N=100 ) with a prospect i ve group  who received some form of perioperative oral multiodal analgesis ( N=100 ) . The new regimen included preoperative and postoperative scheduled extended-release oxycodone , gabapentin , and acetaminophen , intraoperative dolasetron and as-needed postoperative short-acting oral oxycodone . Patient surveys and chart audits were used to measure pain intensity , functional interference from pain , opioid consumption , analgesic-related side effects , and patient satisfaction over the first 24 hours postoperatively . Results Patients who received the new perioperative multimodal oral regimen had significantly less opioid consumption ( P<0.001 ) , lower ratings of Least Pain ( P<0.01 ) , and experienced less nausea ( P<.001 ) , drowsiness ( P<0.05 ) , interference with walking ( P=0.05 ) , and coughing and deep breathing ( P<0.05 ) compared with the IV PCA group . Conclusions This quality improvement study shows some safety and significant advantages of a multimodal perioperative oral analgesic regimen compared with st and ard IV PCA after spine surgery BACKGROUND Postoperative analgesia with the use of parenteral opioids or epidural analgesia can be associated with troublesome side effects . Good perioperative analgesia facilitates rehabilitation , improves patient satisfaction , and may reduce the hospital stay . We investigated the analgesic effect of locally injected drugs around a total knee prosthesis . METHODS Sixty-four patients undergoing total knee arthroplasty were r and omized either to receive a periarticular intraoperative injection containing ropivacaine , ketorolac , epimorphine , and epinephrine or to receive no injection . The perioperative analgesic regimen was st and ardized . All patients in both groups received patient-controlled analgesia for twenty-four hours after the surgery , and this was followed by st and ard analgesia .  Visual analog scores for pain , during activity and at rest , and for patient satisfaction were recorded preoperatively and postoperatively and at the six-week follow-up examination . The consumption of patient-controlled analgesia at specific postoperative time-points and the overall analgesic requirement were measured . RESULTS The patients who had received the injection used significantly less patient-controlled analgesia at six hours , at twelve hours , and over the first twenty-four hours after the surgery . In addition , they had higher visual analog scores for patient satisfaction and lower visual analog scores for pain during activity in the post-anesthetic-care unit and four hours after the operation . No cardiac or central nervous system toxicity was observed . CONCLUSIONS Intraoperative periarticular injection with multimodal drugs can significantly reduce the requirements for patient-controlled analgesia and improve patient satisfaction , with no apparent risks , following total knee arthroplasty The number of total knee arthroplasty ( TKA ) procedures continuously increases , with good to excellent results . In the last few years , new surgical techniques have been developed to improve prosthesis positioning . In this context , patient-specific instrumentation is included . The goal of this study was to compare the perioperative parameters and the spatial positioning of prosthetic components in TKA procedures performed with patient-specific instrumentation vs traditional TKA . In this prospect i ve comparative r and omized study , 15 patients underwent TKA with 3-dimensional magnetic resonance imaging ( MRI ) preoperative planning ( patient-specific instrumentation group ) and 15 patients underwent traditional TKA ( non-patient-specific instrumentation group ) . All patients underwent postoperative computed tomography ( CT ) examination .  In the patient-specific instrumentation group , preoperative data planning regarding femoral and tibial bone resection was correlated with intraoperative measurements . Surgical time , length of hospitalization , and intraoperative and postoperative bleeding were compared between the 2 groups . Positioning of implants on postoperative CT was assessed for both groups . Data planned with 3-dimensional MRI regarding the depth of bone cuts showed good to excellent correlation with intraoperative measurements . The patient-specific instrumentation group showed better perioperative outcomes and good correlation between the spatial positioning of prosthetic components planned preoperatively and that seen on postoperative CT . Less variability was found in the patient-specific instrumentation group than in the non-patient-specific instrumentation group in spatial orientation of prosthetic components . Preoperative planning with 3-dimensional MRI in TKA has a better perioperative outcome compared with the traditional method . Use of patient-specific instrumentation can also improve the spatial positioning of both prosthetic components Total knee arthroplasty ( TKA ) is a frequently performed procedure in orthopaedic surgery . Recently , patient-specific instrumentation was introduced to facilitate correct positioning of implants . The aim of this study was to compare the early clinical results of TKA performed with patient-specific CT-based instrumentation and conventional technique . A prospect i ve , r and omized controlled trial on 112 patients was performed between January 2011 and December 2011 . A group of 112 patients who met the inclusion and exclusion criteria were enrolled in this study and r and omly assigned to an experimental or control group . The experimental group comprised 52 patients who received the Signature CT-based implant positioning system , and the control group consisted of 60 patients with conventional instrumentation .  Clinical outcomes were evaluated with the KSS scale , WOMAC scale , and VAS scales to assess knee pain severity and patient satisfaction with the surgery . Specified in-hospital data were recorded . Patients were followed up for 12 months . At one year after surgery , there were no statistically significant differences between groups with respect to clinical outcomes and in-hospital data , including operative time , blood loss , hospital length of stay , intraoperative observations , and postoperative complications . Further high- quality investigations of various patient-specific systems and longer follow-up may be helpful in assessing their utility for TKA This study investigated the physical and psychosocial consequences of living with osteoarthritis ( OA ) in daily life and peoples ’ views of total knee arthroplasty ( TKA ) and the role of physiotherapy . In-depth interview data were used from a prospect i ve qualitative study conducted by the senior author ( KY ) . Participants were 15 volunteers with knee OA who were awaiting TKA at a specialized orthopaedic tertiary care facility in Toronto . A modified grounded theory method approach was used to analyze the interview data . The findings showed that experiences for the participants with OA were conceptualized as a “ breakpoint . ” The breakpoint was centred on the experiences/processes of living with unremitting pain , the limitations of mobility , leisure and social activities , and the result ing consequences to the participant 's physical and psychological well-being . In addition to the above experiences , participants also discussed their perceptions of  TKA surgery .  The findings showed that expectations of TKA were linked to participants ’ knowledge of the procedure and its outcomes . The participants listed acquaintances , friends , family members , and doctors as the main sources of knowledge for TKA . On the basis of the above analysis , recommendations are made for developing a preoperative physiotherapy program that would focus on minimizing preoperative disability and maximizing postoperative recovery Inadequate control of postoperative pain after orthopedic procedures may trigger complications that increase morbidity . Multimodal analgesia is used to manage pain effectively after surgical procedures and reduce the need for rescue analgesia . Intravenous ( IV ) acetaminophen ( OFIRMEV ; Cadence Pharmaceuticals , Inc. ) , an analgesic that has been studied and used in the multimodal management of acute pain after major orthopedic procedures , combines the safety seen with oral and rectal formulations with a preferred route of administration . Two double-blind , r and omized , placebo-controlled clinical trials were conducted ( total 130 patients ) to determine the efficacy and safety of single-dose IV acetaminophen in patients following total hip arthroplasty . Although both studies were stopped prematurely , overlap in patient population s , study design , and method ologies in the single-dose phase of these studies allowed for analysis of their results to be presented concurrently . Both trials demonstrated IV acetaminophen having greater efficacy than placebo in terms of primary endpoints [ pain intensity differences from T0.5 to T3 ( P < 0.05 in both studies ) ] . The use of IV acetaminophen also reduced the need for rescue opioid consumption , with patients receiving IV acetaminophen consuming , on average , less than half the amount of rescue medication as those receiving placebo . IV acetaminophen was effective in treating moderate-to-severe pain after total hip arthroplasty and reduced the need for rescue opioid consumption There is an increasing drive to make nursing care evidence -based . High quality evidence from systematic review s relevant to postoperative pain relief exists , yet pain after surgery remains poorly controlled for many patients . This study aim ed to assess whether implementing evidence -based pain management improved postoperative pain outcomes . Pain on a 0 - 10 scale was the primary outcome and analgesic consumption a secondary outcome . A baseline audit was undertaken on four surgical wards to establish whether there was a need for the study . A r and omized-controlled trial was then design ed to assess the effects of implementing an evidence -based approach to postoperative pain management .  The four wards were r and omized to receive the intervention or act as a control . Outcomes were assessed 3 months after the intervention on both intervention and control wards . The intervention ( implementation of an oral analgesic algorithm derived from systematic review s ) was then implemented on the control wards and outcomes reassessed after 3 months on the control wards . The intervention was design ed using an evidence -based approach to effective implementation . Four interactive sessions covered : ( 1 ) detailed feedback of baseline data and discussion ( utilizing audit and feedback ) , ( 2 ) why systematic review s , analgesic league tables and choice of drugs to develop an analgesic algorithm ( see Figure 1 ) , ( 3 ) principles of evidence based health care ( EBHC ) , including critical appraisal and ( 4 ) facilitation and change workshop . The findings revealed no significant differences in pain level or drug use between the intervention and control wards . However , the control wards also changed during the control period . Possible explanations for this are discussed . When looking at changes compared with baseline , both intervention and control wards increased their use of algorithm drugs and reduced use of non-algorithm drugs during the study . No effects were found on pain in the intervention wards . Pain ratings at rest since surgery , on movement since surgery and worst pain on movement were significantly reduced compared with baseline in the control wards . Although there are many pressures to utilize a r and omized-controlled trial study design in the culture of evidence -based health care , there will be times , especially when implementing complex changes in practice that other types of design should be considered BACKGROUND The main objective of this prospect i ve r and omized study was to compare the clinical and radiographic outcomes of the mini-midvastus ( MMV ) approach with the conventional approach for total knee arthroplasty at the 5-year follow-up . METHODS Ninety-seven patients ( 100 knees ) with osteoarthritis were assigned to the MMV  group or to a group receiving conventional total knee arthroplasty .  Intraoperative and postoperative clinical data were collected . At 6 weeks and at 1 , 2 , and 5 years postoperatively , the Knee Injury and Osteoarthritis Outcome Score ( KOOS ) , the Oxford Knee Score ( OKS ) , the Knee Society Score ( KSS ) , and the Short Form (SF)-12 were completed . Radiographs of the knee were made preoperatively and at 1 day and 1 and 5 years postoperatively . Computed tomography ( CT ) scans were performed 2 years postoperatively . RESULTS In the MMV group , the mean skin incision was 2.5 cm shorter ( p < 0.001 ) and the mean duration of the operation was 6 minutes longer than in the conventional total knee arthroplasty group ( p < 0.05 ) . Eight patients in the conventional group had a lateral parapatellar retinacular release compared with 1 in the MMV group ; the difference was significant ( p = 0.01 ) . Three intraoperative complications , including 2 small lateral femoral condylar fractures and 1 partial patellar tendon laceration , occurred in the MMV group . Seven patients in the MMV group had postoperative blisters ; all of them had a relatively large femoral component and 4 of them were large men . The radiographs and CT scans of the prostheses showed no significant differences between the MMV and conventional groups except for the posterior slope of the tibial component . In addition , no significance differences were detected between the groups with respect to the KOOS , OKS , KSS , and SF-12 scores determined at the 6-week and the 1 , 2 , and 5-year follow-up evaluations . CONCLUSIONS In the rehabilitation period and at the short and mid-term follow-up , no relevant clinical and radiographic differences were found between the MMV and the conventional approach for total knee arthroplasty , making the advantage of MMV total knee arthroplasty cosmetic . We discourage the use of the MMV approach in large male patients because of the increased number of intraoperative complications and skin blisters postoperatively . LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence Acupuncture has been used therapeutically in China for thous and s of years and is growing in prominence in Europe and the United States . In a recent review of complementary and alternative medicine use in the US population , an estimated 2.1 million people or 1.1 % of the population sought acupuncture care during the past 12 months . Four percent of the US population used acupuncture at any time in their lives . We review ed 31 different published journal articles , including 23 r and omized controlled clinical trials and 8 meta- analysis / systematic review s. We found evidence of some efficacy and low risk associated with acupuncture in pediatrics . From all the conditions we review ed , the most extensive research has looked into acupuncture 's role in managing postoperative and chemotherapy-induced nausea/vomiting . Postoperatively , there is far more evidence of acupuncture 's efficacy for pediatrics than for children treated with chemotherapy . Acupuncture seems to be most effective in preventing postoperative induced nausea in children . For adults , research shows that acupuncture can inhibit chemotherapy-related acute vomiting , but conclusions about its effects in pediatrics can not be made on the basis of the available published clinical trials data to date . Besides nausea and vomiting , research conducted in pain has yielded the most convincing results on acupuncture efficacy . Musculoskeletal and cancer-related pain commonly affects children and adults , but unfortunately , mostly adult studies have been conducted thus far . Because the manifestations of pain can be different in children than in adults , data can not be extrapolated from adult research . Systematic review s have shown that existing data often lack adequate control groups and sample sizes . Vas et al , Alimi et al , and Mehling et al demonstrated some relief for adults treated with acupuncture but we could not find any well-conducted r and omized controlled studies that looked at pediatrics and acupuncture exclusively . Pain is often unresolved from drug therapy , thus there is a need for more studies in this setting . For seasonal allergic rhinitis , we review ed studies conducted by Ng et al and Xue et al in children and adults , respectively . Both population s showed some relief of symptoms through acupuncture , but questions remain about treatment logistics . Additionally , there are limited indications that acupuncture may help cure children afflicted with nocturnal enuresis . Systematic review s show that current published trials have suffered from low trial quality , including small sample sizes . Other areas of pediatric afflictions we review ed that suffer from lack of research include asthma , other neurologic conditions , gastrointestinal disorders , and addiction . Acupuncture has become a dominant complementary and alternative modality in clinical practice today , but its associated risk has been question ed . The National Institutes of Health Consensus Statement states “ one of the advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or other accepted procedures for the same conditions . ” A review of serious adverse events by White et al found the risk of a major complication occurring to have an incidence between 1:10,000 and 1:100,000 , which is considered “ very low . ” Another study found that the risk of a serious adverse event occurring from acupuncture therapy is the same as taking penicillin . The safety of acupuncture is a serious concern , particularly in pediatrics . Because acupuncture 's mechanism is not known , the use of needles in children becomes question able . For example , acupoints on the vertex of infants should not be needled when the fontanel is not closed . It is also advisable to apply few needles or delay treatment to the children who have overeaten , are overfatigued , or are very weak . Through our review of pediatric adverse events , we found a 1.55 risk of adverse events occurring in 100 treatments of acupuncture that coincides with the low risk detailed in the studies mentioned previously . The actual risk to an individual patient is hard to determine because certain patients , such as an immunosuppressed patient , can be predisposed to an increased risk , acupuncturist 's qualifications differ , and practice s vary in certain parts of the world . Nevertheless , it seems acupuncture is a safe complementary/alternative medicine modality for pediatric patients on the basis of the data we review ed BACKGROUND There are few data on the associations between anaemia , allogeneic blood transfusion ( ABT ) , patient blood management , and outcome after arthroplasty in the UK . National agencies nevertheless instruct NHS Trusts to implement blood conservation measures including preoperative anaemia management . Internationally , blood management programmes show encouraging results . METHODS We retrospectively audited 717 primary hip or knee arthroplasties in a UK general hospital and conducted regression analyses to identify outcome predictors . We used these data to modify previously published algorithms for UK practice and audited its introduction prospect ively . The retrospective audit group served as a control . RESULTS Preoperative haemoglobin ( Hb ) concentration predicted ABT ( odds ratio 0.25 per 1 g dl(-1 ) , P<0.001 ) . It also predicted the length of stay ( LOS , effect size -0.7 days per 1 g dl(-1 ) , P=0.004 ) independently of ABT , including in non-anaemic patients . Patient blood management implementation was associated with lower ABT rates for hip ( 23 - 7 % , P<0.001 ) and knee ( 7 - 0 % , P=0.001 ) arthroplasty . LOS for total hip replacement and total knee replacement decreased from 6 ( 5 - 8 ) days to 5 ( 3 - 7 ) and 4 ( 3 - 6 ) days , respectively , after algorithm implementation ( P<0.001 ) . The all-cause re-admission rate within 90 days decreased from 13.5 % ( 97/717 ) before to 8.2 % ( 23/281 ) after algorithm implementation ( P=0.02 ) . CONCLUSIONS We conclude that preoperative Hb predicts markers of arthroplasty outcome in UK practice . A systematic approach to optimize Hb mass before arthroplasty and limit Hb loss perioperatively was associated with improved outcome up to 90 days after discharge Surgical injury is followed by pain , stress-induced catabolism , impairment of organ function , and a risk of thromboembolism and impaired cognitive function . These events may contribute to complications , a need for prolonged hospitalization , postoperative fatigue , delayed convalescence , and the need for rehabilitation . Optimization of the individual care components in perioperative care ( the fast-track methodology ) reduces the need for hospitalization , morbidity , and prolonged convalescence , with subsequent economic savings ( Kehlet and Wilmore 2008 ) . Correspondingly , improvement in perioperative care has led to a reduced stay in hospital after total hip arthroplasty ( THA ) and total knee arthroplasty ( TKA ) , which is now only about 3 days in many centers . The main question that remains to be answered is whether further improvement can be made and whether these operations can be performed on an ambulatory or semi-ambulatory basis without any increased risk of morbidity or cardiopulmonary and thromboembolic complications , long-term cognitive dysfunction , pain , and need for rehabilitation . Thus , a multidisciplinary collaboration has been established in 5 dedicated public Danish hospitals with established fast-track THA and TKA in order to optimize perioperative care to require only 1–2 days of hospitalization with no increase in post-discharge pain , morbidity , and rehabilitation requirements ( Figure ) . To this end , we concentrated on  perioperative pain management , optimization of transfusion strategies , strategies for postoperative rehabilitation , requirements for postoperative thromboembolic prophylaxis , and safety aspects ( re-admissions , hip dislocation , and knee stiffness ) . Effective postoperative pain relief is a prerequisite for a successful fast-track recovery . Although continuous peripheral nerve blocks are currently the most effective analgesic techniques ( Ilfeld et al. 2008a , b ) , they are dem and ing in terms of expertise and there is a risk of muscle paralysis . Efforts have therefore been made recently to improve local wound infiltration and infusion techniques . Although promising , more research is required to better define these techniques regarding dose-volume relationships , placement and types of catheters , duration , and safety aspects ( Rostlund and Kehlet 2007 ) . There will be more focus on post-discharge pain , which remains a problem in many patients . Furthermore , research will concentrate on mechanisms and predictors of the large inter-individual variability in the degree of postoperative pain , which may be related to the inflammatory response and genes associated with pain . Such knowledge should facilitate pain management , leading to differential use of analgesic principles in low pain responders and high-pain responders . Blood transfusion is indicated when a patient 's limit concerning — or physiological adaptation to — progressive normovolemic anemia is reached , but there are no specific data from THA and TKA . Data from hip fracture surgery have shown that postoperative anemia impedes functional mobility and that a liberal transfusion strategy reduces morbidity ( Foss et al. 2009 ) . Since modern blood transfusion is safer than before , large r and omized studies with high and low transfusion thresholds will be performed in cardiovascular high-risk patients after THA , with morbidity and functional recovery as primary outcome measures . Postoperative rehabilitation after THA and TKA has been st and ard despite the fact that there has been little evidence on the optimal type of physiotherapy , when it should be started , and for how long ( Minns Lowe et al. 2007 , 2009 ) . Previous r and omized studies have been inconclusive and they were based on relatively long-term hospitalization ( 7–12 days ) ; they are therefore not applicable to fast-track THA and TKA . Over the last decade , many industry-sponsored trials have documented the need for prolonged thromboembolic prophylaxis ( 10–30 days ) , mostly based on surrogate outcomes and with relatively small effects on clinical manifestations of thromboembolism ( Geerts et al. 2008 ) . A common characteristic of these studies has been a relatively long hospital stay ( 6–12 days or more ) . Since postoperative immobilization is a well-known risk factor for postoperative thromboembolism , the need for prolonged thromboembolic prophylaxis after implementation of fast-track surgery with early mobilization might be question ed . The fast-track group will therefore focus on a large ( n = 5,000 ) prospect i ve , detailed 90-day follow-up study with prophylaxis only until discharge ( 1–3 days ) . It is well-documented that cognitive function declines after THA and TKA in elderly patients ( Maze et al. 2008 ) . A fast-track setup may reduce cognitive dysfunction due to less postoperative sleep disturbances , less pain , and less opioid requirements , all of which may impair cognitive function . Finally , in the fast-track THA and TKA setting , safety aspects will be assessed regarding the risk of hip dislocation , and knee stiffness after TKA . In summary , despite major improvements in care and short-term outcome after THA and TKA , several issues remain to be answered in order to optimize fast-track treatment Clinical registries play an important role in measuring healthcare delivery and supporting quality improvement for individuals with cardiovascular disease and stroke . Well- design ed clinical registry programs provide important mechanisms to monitor patterns of care , evaluate healthcare effectiveness and safety , and improve clinical outcomes . The use of clinical registries is likely to grow given the increasing focus on measuring and improving healthcare delivery and patient outcomes by stakeholders in both the private and public sectors . The American Heart Association ( AHA ) has a longst and ing commitment to promoting the innovative and effective use of clinical registries . The importance of clinical registries was highlighted recently in an AHA Scientific Statement on “ Essential Features of a Surveillance System to Support the Prevention and Management of Heart Disease and Stroke ” in the United States.1 This policy statement exp and s on the previous scientific statement by providing recommendations to policy makers and the healthcare community for expansion of the applications of existing and future clinical registries . The term “ clinical registry ” is defined here as an observational data base of a clinical condition , procedure , therapy , or population in which there are often no registry-m and ated approaches to therapy and relatively few inclusion or exclusion criteria . The focus of clinical registries is to capture data that reflect “ real-world ” clinical practice in large patient population s. The data from clinical registries do not replace the need for traditional r and omized controlled trials . Rather , registries and trials are complementary approaches , each with unique advantages and imperfections.2 Such clinical registries do not solely contain cl aims or administrative data yet may be linked to such data sources . There are at least 3 classifications of clinical registries based on the patient population , including procedure/therapy/encounter-based , disease-based , and population -based registries . Registries also can be classified from a functional perspective , such as whether the registry is used to conduct clinical research , PURPOSE OF THE STUDY There have been few prospect i ve studies comparing minimally invasive approaches for total hip replacement . We wanted to ascertain the contribution of the minimally invasive posterior approach in comparison with the st and ard posterolateral approach in terms of early outcome . MATERIAL S AND METHODS This was prospect i ve comparative consecutive series of patients . Patients with major architectural problems or undergoing revision arthroplasty were excluded . One hundred ten patients ( 116 hips ) were divided into two groups which were comparable for number of patients , gender , age , body mass index , indication for surgery , and preoperative function scores . The preoperative ASA score was lower in the minimally invasive group ( p=0.04 ) . The patients were in the lateral reclining position for the two approaches and classical instrumentation using the same implants ( stems and cemented or non-cemented cups ) were used . We noted operative time and blood loss ( using the Brecher method based on the hematocrit at day 1 and 5 and the number of blood transfusions ) , postoperative pain , and implant position . Functional outcome was assessed with the modified Harris score and the WOMAC index ( at 6 weeks and 3 and 6 months ) . Statview(R ) was used to search for statistical significance considering p<0.05 as significant . RESULTS Mean length of incision was 8.5 cm versus 15.1 cm . Mean blood loss was significantly less in the minimally invasive group ( p=0.027 ) as was the level of postoperative pain as confirmed by the lesser consumption of morphine analgesics ( p=0.006 ) . Other operative variables as well as implant position were comparable . There were no major complications in the minimally invasive group . In the st and ard group , there was one case of common peroneal nerve palsy , two dislocations , and two fractures related to falls after prosthesis implantation . The WOMAC index was better after the minimally invasive approach at six weeks and at three months ( p<0.05 ) . The modified Harris score was better only at six weeks . Functional outcome and pain became comparable thereafter . DISCUSSION AND CONCLUSION The minimally invasive posterior approach does not require an orthopedic table nor specific instrumentation . A minute procedure is required with ligature of the posteromedial circumflex artery of the thigh to improve exposure and limit intraoperative bleeding . It enables satisfactory reproducible implant positioning . Conversion to an open posterolateral approach is possible if needed . The minimally invasive posterior approach enables a reduction in intraoperative bleeding and in postoperative pain while allowing earlier more rapid rehabilitation . Early clinical outcome is better but beyond six weeks , the functional results are comparable for the two approaches . The minimally invasive posterior approach is a reliable reproducible approach with a progressive learning curve Local infiltration anesthesia ( LIA ) with anesthetics , steroids , NSAIDS , and epinephrine has been shown to be effective in reducing total knee arthroplasty ( TKA ) postoperative pain . This systematic review explores the functional outcomes of r and omized control trials that have compared the use of LIA with and without steroids during TKA . Five studies with 412 patients met the inclusion criteria , 228 received local infiltration anesthesia with steroids ( LIAS ) and 184 received local infiltration anesthesia without steroids ( LIAWS ) . The use of LIAS in management of postoperative TKA pain has been shown to decrease the length of hospital stay , time required to achieve straight leg raise , and pro-inflammatory signals in patients . Although there is no overwhelming data to suggest LIAS  improves postoperative TKA pain , current literature does support its effectiveness in producing other favorable surgical outcomes Background and purpose — Acute myocardial infa rct ion ( MI ) is a leading cause of mortality following total hip and knee arthroplasty ( THA/TKA ) . The reported 30-day incidence of MI varies from 0.3 % to 0.9 % . However , most data derive from administration and insurance data bases or large RCTs with potential confounding factors . We studied the incidence of and potential modifiable risk factors for postoperative MI in a large , multicenter optimized “ fast-track ” THA/TKA setting . Patients and methods — A prospect i ve cohort study was conducted on consecutive unselected elective primary unilateral THA and TKA  , using prospect i ve information on comorbidities and complete 90-day follow-up from the Danish National Patient Registry . Evaluation of discharge summaries and medical records was undertaken in cases of suspected MI . Logistic regression analyses were carried out for identification of preoperative risk factors . Results — Of 24,862 procedures with a median length of stay 2 ( IQR 2–3 ) days , 30- and 90-day incidence of MI was 31 ( 0.12 % ) and 48 ( 0.19 % ) . Preoperative risk factors for MI ≤30 days were age > 85 years ( OR 7.4 , 95 % CI 2.3–24 ) , insulin-dependent diabetes mellitus ( IDDM ) ( 3.6 , CI 1.1–12 ) , cardiovascular disease ( 2.4 , CI 1.1–5.0 ) and hypercholesterolemia ( 2.3 , CI 1.1–5.1 ) . Of 31 patients with MI ≤30 days 9 were treated with vasopressors for intraoperative hypotension and 27 had postoperative anemia . Interpretation — Fast-track THA and TKA had a low 30-day MI incidence . Focus on patients with age > 85 , IDDM , cardiovascular disease , and hypercholesterolemia may further reduce the 30-day incidence of MI . The role of postoperative anemia and intraoperative hypotension are other areas for further Background : Whether to resurface the patella during a primary total knee arthroplasty performed for the treatment of degenerative osteoarthritis remains a controversial issue . Parameters that have been suggested as being useful in guiding this decision include patient height and weight , the presence of anterior knee pain preoperatively , and the grade of chondromalacia encountered intraoperatively . The purpose of this study was to determine whether these parameters were predictive of the clinical result following total knee arthroplasty with or without patellar resurfacing . Methods : Eighty-six patients ( 118 knees ) undergoing primary total knee arthroplasty for the treatment of osteoarthritis were enrolled in a prospect i ve , r and omized , double-blind study . All patients received the same posterior-cruciate-sparing total knee prosthetic components . Patients were r and omized to treatment with or without resurfacing of the patella . Evaluations consisted of the determination of a Knee Society clinical score , the completion of a patient satisfaction question naire , specific questions relating to patellofemoral symptoms , and radiographs .  Sixty-seven patients ( ninety-three knees ) were followed for a minimum of five years ( range , sixty to eighty-four months ; average , 70.5 months ) . Results : With the numbers available , there was no significant difference between the groups treated with and without resurfacing with regard to the overall Knee Society score or the pain and function subscores . Obesity , the degree of patellar chondromalacia , and the presence of preoperative anterior knee pain did not predict postoperative clinical scores or the presence of postoperative anterior knee pain . Conclusions : The occurrence of anterior knee pain could not be predicted with any clinical or radiographic parameter studied . On the basis of these results , it seems likely that postoperative anterior knee pain is related either to the component design or to the details of the surgical technique , such as component rotation , rather than to whether or not the patella is resurfaced During a two-year period , eighty-nine patients who were scheduled to have a total knee arthroplasty for the treatment of degenerative osteoarthrosis were r and omly assigned to one of two groups : resurfacing of the patella or retention of the patella . All patients received the same  posterior cruciate-sparing prosthesis  , and all operations were performed by , or under the direct supervision of , one of us . Three patients died in the early postoperative period . The remaining eighty-six patients ( 118 knees ; fifty-eight that had had resurfacing of the patella and sixty that had not ) formed the study group . They were followed for a mean of thirty months ( range , twenty-four to forty-four months ) . Evaluation was performed with use of the clinical scoring system of The Knee Society , a patient-satisfaction question naire , specific questions regarding patellofemoral symptoms and function , and radiographs . All clinical evaluations were performed by the same research nurse , without the involvement of a physician , in a blinded manner ( neither the nurse nor the patient had knowledge of whether the patella had been resurfaced ) . Preoperatively , the mean Knee Society score , on a scale ranging from 0 to 200 points , was 89.7 points ( range , 33 to 132 points ) ; postoperatively , this score improved to a mean of 172.7 points ( range , 98 to 200 points ) . With the numbers available for study , we could detect no significant difference between the knees that had had patellar resurfacing and those that had not with regard to the over-all score ( p = 0.63 ) , the subscore for pain ( p = 0.56 ) , or the subscore for function ( p = 0.77 ) . We also could detect no difference between the treatment groups , with the numbers available , with regard to patient satisfaction or the responses to questions involving the function of the patellofemoral joint , including the ability to exit from an automobile , to rise from a chair , and to climb stairs .  Thirty-two patients had bilateral total knee replacement with resurfacing of the patella in one knee and retention of the patella in the other . These patients expressed no clear preference for either knee . Eight ( 13 per cent ) of the sixty knees that had not had resurfacing were painful anteriorly compared with four ( 7 per cent ) of the fifty-eight that had ; this was not a significant difference ( p = 0.38 ) , with the numbers available . The anterior pain that was noted postoperatively was predominantly of new onset ; it had not been observed preoperatively in three of the four knees that had had resurfacing or in four of the eight that had not . No additional treatment options were offered to the patients who had anterior pain in the knee after resurfacing . However , six ( 10 per cent ) of the sixty knees that had not had resurfacing had it subsequently , because of anterior pain in the knee , after the twelfth postoperative month ( range , fifteen to thirty-nine months ) . The pain decreased in four of these knees . Thus , total knee arthroplasty with retention of the patella yielded clinical results that were comparable with those after total knee arthroplasty with patellar resurfacing , but it was associated with a 10 per cent prevalence of the need for subsequent resurfacing . The prevalence of anterior pain after total knee arthroplasty was not influenced by whether or not the patella had been resurfaced . The postoperative clinical scores , the postoperative development of anterior pain , and the need for subsequent resurfacing were not predicted by the presence of preoperative anterior pain , obesity , or the grade of chondromalacia observed intraoperatively . Because of the short duration of follow-up , these results should be considered preliminary . Additional follow-up is planned BACKGROUND Physicians are often asked about complementary therapies by patients with cancer , and data show that the interest in and use of these therapies among patients with cancer is common . Therefore , it is important to assess the current evidence base on the benefits and risks of complementary therapies ( modalities not historically used in modern Western medicine ) . METHODS A systematic literature review was carried out and recommendations were made according to the American College of Chest Physicians Evidence -Based Clinical Practice Guidelines development methodology . RESULTS A large number of r and omized controlled trials , systematic review s , and meta-analyses , as well as a number of prospect i ve cohort studies , met the predetermined inclusion criteria . These trials addressed many different issues pertaining to patients with lung cancer , such as symptoms of anxiety , mood disturbance , pain , quality of life , and treatment-related side effects . The available data cover a variety of interventions , including acupuncture , nutrition , mind-body therapies , exercise , and massage . The body of evidence supports a series of recommendations . An evidence d-based approach to modern cancer care should integrate complementary therapies with st and ard cancer therapies such as surgery , radiation , chemotherapy , and best supportive care measures . CONCLUSIONS Several complementary therapy modalities can be helpful in improving the overall care of patients with lung cancer This analysis of retrospective and prospect i ve data quantified children ( age range 0 - 18 years , total n = 132 ) during their stay in a cardiothoracic intensive care unit and examined pain management and sedation practice s. Data on both factors that could potentially affect pain and its management , and analgesics/sedatives ordered for and administered to subjects were collected from chart review . In the prospect i ve group , pain intensity was measured twice daily using the Wong-Baker FACES Pain Rating Scale . Repeat cardiac surgical procedure subjects reported significantly more pain than nonrepeat subjects on the first postoperative night . Subjects with sternal incisions  reported significantly more pain than subjects with submammary incisions . Not all subjects were premedicated with analgesia for invasive procedures . Significantly greater amounts of analgesia were received by the 0 - 3 year-old subjects . Large amounts of  sedation  were used , especially in children under 3 years of age . The results prompted development of a nursing st and ard to assess and manage pain and sedation in this population Since its introduction in the 1990s , the concept of multimodal perioperative care ( fast-track surgery , enhanced recovery programmes ) has gained widespread acceptance and is now considered as a st and ard of care . Most studies that support this approach relate to colorectal surgery , but similar data have been published across surgical specialties with major economic benefits 1–4 . The implementation process has been described in detail and is essentially based on the simple question : ‘ Why is the postoperative patient in hospital today?’1,5 . The relevant question may therefore be asked – what next ? Postoperative length of stay is often seen as the key outcome for fast-track surgery and , although this may not always be appropriate , whatever is used as a primary outcome measure must be justified adequately . It should also be emphasized that significant progress in fast-track care dem and s inclusion and implementation of all of its basic components . Many studies have not implemented the most important aspects of the care programmes that were originally described , including patient information , effective thoracic epidural analgesia with sufficient local anaesthetic that facilitates early mobilization , reduced ileus and rapid re introduction of oral feeding , or the use of non-opioid analgesia , where appropriate , in open or minimally invasive surgery . An important issue that needs to be addressed in future is detailed analysis of ‘ medical ’ versus ‘ surgical ’ morbidity6 . To improve further our underst and ing of perioperative risk , future studies must analyse how one specific complication might lead to another : for instance , whether a pneumonia or myocardial infa rct ion led to an anastomotic dehiscence ; or a wound dehiscence with reoperation led to a subsequent pneumonia , myocardial infa rct ion or thromboembolic complication6 . Initial ‘ medical ’ morbidity may depend on perioperative care principles and pre-existing comorbidity , in contrast to an initial ‘ surgical ’ complication , which may depend on surgical technique , and therefore require a different approach from fast-track methodology . How might the fast-track approach evolve further , as surgeons perform an ever-increasing number of major procedures in older patients with comorbidities , with greater risks of postoperative complications , prolonged hospital stay and death6 ? Preoperative evaluation of operative risk may not be helpful unless evidence -based perioperative interventions are available and instituted . Thus , the specific role of preoperative morbidity , such as smoking , diabetes and cardiopulmonary disease , in determining the risk of postoperative morbidity needs to be reassessed in studies with a fully implemented fast-track procedure-specific programme6 . We also need to have a second look at the relative roles of the different components of the fast-track programme ( for example type of analgesia and fluid management1,5 ) and analyse where progress can be made in order to reduce perioperative risk and morbidity , instead of focusing on length of stay as the primary outcome . The surgical stress response is proportional to the degree of insult and the main factor that contributes to postoperative organ dysfunction1,2 . Every effort should therefore be made to reduce those responses that are undesirable . Regional anaesthetic techniques have a powerful effect on the catabolic response , reducing cardiac dem and s , pain , pulmonary dysfunction and ileus .  Regional anaesthesia should be used whenever possible on a procedure-specific basis7 . Inflammatory responses contribute to pain , fatigue and organ dysfunction . They can be modified pharmacologically by preoperative glucocorticoids8 . Significant reductions in pain , nausea and vomiting , and early fatigue have been demonstrated , facilitating early recovery , so far without demonstrable side-effects . More procedure-specific and dosefinding studies are required . A single preoperative glucocorticoid dose in a larger amount than used for conventional nausea and vomiting prophylaxis might , for instance , be an important contributory factor to improving fast-track programmes in high-risk patients . Minimally invasive surgery also reduces the inflammatory response , although the contribution that this plays in the context of fast-track programmes in colonic surgery is difficult to interpret , as the care programmes used in the ‘ open ’ groups have often not been fully implemented6,9,10 . Therefore , future efforts to assess early postoperative outcome effects of minimally invasive surgery should include r and omized studies with fully implemented fasttrack programmes11 . Newer developments in minimally invasive AIMS Population -based cancer registries can provide excellent data for insight in disease management practice . This study examines the extent to which the consensus-based national clinical guidelines ( version 2000 - 2001 ) for colorectal cancer ( CRC ) had been implemented in the diagnostic and treatment approach in the Southern Netherl and s in 2002 . METHODS Data were gathered from the medical records for a r and om sample from the Eindhoven Cancer Registry of 308 patients with colorectal cancer . Adherence to clinical guidelines was determined for diagnostic assessment , pathology , and treatment during the first year after diagnosis . RESULTS Surgical procedures and referral for pre-operative radiotherapy were carried out largely conform the recommendations . The number of performed colonoscopies  among colon cancer patients amounted to 60 % ; contrast enemas after incomplete colonoscopy  were performed in only 27 % of patients . The median number of examined lymph nodes was only six for patients with colon and five for patients with rectal cancer ; the administration of adjuvant chemotherapy  for patients with stage III colon cancer decreased from 95 % of patients younger than 70 years to 48 % of patients over 70 . CONCLUSIONS Adherence to clinical guidelines was not optimal . Feedback to surgeons and pathologists should improve adherence , especially with respect to nodal retrieval and assessment
Taking knee arthroplasty as an example , patients deemed at low risk of experiencing outcomes such as postoperative pain or chronic pain  may receive intra-articular local anaesthesia infiltration ;  patients at medium risk may obtain additional analgesia via a saphe-nous nerve catheter ; and patients at high risk may also receive nerve blocks and anti-hyperalgesics .
pain and function after fast-track hip and knee arthroplasty .
catastrophizing , response to experimental heat stimuli , and post-cesarean section pain .
In 1946 , Mendelson 1 showed that pulmonary complications and death could arise in pregnant women because of aspiration of gastric contents .
Since then , prevention of aspiration of gastric contents has contributed significantly to a decrease in maternal deaths .
Warner and colleagues 2 demonstrated in a large series from the Mayo Clinic that no aspiration occurred in pregnant or post-partum women ( probably because of the routine use of prophylactic measures ) , while both its occurrence and severity were significant in emergency procedures .
formation of large informatic data bases , or clinical quality registries , linking preoperative and intraoperative clinical data , imaging , genomics , and cancer and drug prescription data bases .
References 1 Fischer HB , Simanski CJ , Sharp C , et al. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty .
Postoperative pain management : number-needed-to-treat approach versus procedure-specific pain management approach .