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Introduction Femoral neck fractures in the young patient present a unique challenge. Most surgeons managing these injuries prefer a fixed angle implant, however these devices are fraught with problems. A dynamic hip screw (DHS) is one such fixed angle device that risks malreduction through rotational torque during screw insertion. To avoid this risk some surgeons utilize a dynamic helical hip system (DHHS), however little is known about the complication profile of this device. We hypothesized that the complication rate between these two devices would be similar. Patients and Methods All patients presenting to a single tertiary referral center with a femoral neck fracture were identified from a prospectively collected trauma database over an 11-year period. Patients were included if they were less than 60 years of age, treated with a DHS or DHHS, and had at least 6 months of follow-up. Demographic data, injury characteristics, and post-operative complications were obtained through chart review. Standard statistical comparisons were made between groups. A total of 77 patients met inclusion criteria. Results Average age of patients was 38 years (range: 18–59) and 56 (73%) were male. The DHS was used in 37 (48%) patients and the DHHS was used in 40 (52%) patients. Demographic data including average age, gender, body mass index, and smoking status did not differ between the groups. There were 29 (39%) total complications of interest (femoral neck shortening >5 mm, non-union requiring osteotomy, conversion to THA, and osteonecrosis. There were 19 (51%) complications in the DHS group and 10 (25%) in the DHHS group (p = 0.01, risk difference 25%, 95% CI 7–43). Comparisons of the individual complications about the DHS and DHHS cohort did not reach statistical significance for non-union (8% vs 3%) or THA (16% vs 13%) (p = 0.33, p = 0.64, respectively) but a difference was detected in the rate of shortening (27% vs 10%; p = 0.05). Conclusion This study demonstrates a high risk of complication when managing young femoral neck fractures in line with prior literature. The major complication rate of non-union requiring osteotomy or fixation failure resulting in THA was no different between the two groups, but the rate of shortening was greater the DHS group. This data suggests the DHHS may be a suitable device to manage the young femoral neck fracture and without increased risk of complication.

OBJECTIVES: Laser-assisted Indocyanine Green Angiography (LA-ICGA) is a novel method for objectively quantifying soft tissue perfusion. The primary aim of this study was to determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study SETTING: Academic trauma centre PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients that underwent open reduction internal fixation MAIN OUTCOME MEASUREMENTS: Skin perfusion (fluorescence units) as measured by LA-ICGA RESULTS: Six patients were classified as Tscherne grade 0, nine as grade 1, ten as grade 2, and two as grade 3. Perfusion decreased by 14 fu (95% CI: −21, −6, p

Objectives To assess the reliability of the current computed tomography (CT) based technique for determining femoral anteversion, and quantify the prevalence and magnitude of side-to-side differences. Design Cross-sectional cohort study. Setting Academic trauma center. Patients We reviewed CT scans from 120 patients with bilateral full-length axial cuts of both femurs. Two hundred forty femurs with no fractures or other identifying features in their femora were included. Ten unique data sets were created to measure anteversion of the left and right sides. Main outcome measurements Intraobserver and interobserver reliability were calculated using intraclass correlation coefficients (ICC) and pooled absolute differences. The mean absolute difference between the sides was determined using a fixed-effects model. Results Interobserver reliability was high (ICC: 0.85, 95% confidence interval [CI]: 0.83-0.88). The pooled mean absolute magnitude of variation between reviewers was small at 1.6 degrees (95% CI: 1.4-1.8 degrees) per scan. The intraobserver reproducibility was high (ICC: 0.91, 95% CI: 0.88-0.93) with a mean error of 2.7 degrees (95% CI: 2.2-3.1 degrees) per repeat viewing of the same scan by the same person. The magnitude of side-to-side variation was 2.0 degrees (95% CI: 1.5-2.6 degrees). Twenty-one subjects (18%, 95% CI: 12-25%) had a mean side-to-side calculated femoral anteversion difference of ≥10 degrees, while 6 (5%, 95% CI: 2-10) subjects had a calculated mean side-to-side difference ≥15 degrees. Conclusions CT based femoral anteversion measurement techniques demonstrate good precision. Only 1 in 20 patients had side-to-side differences of 15 degrees or more. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

We describe the novel quantitative lesser trochanter profile (QLTP) technique to determine the magnitude and direction of femoral malrotation and to compare its performance with the cortical step sign technique. For this assessment, 9 orthopaedic surgeons estimated the magnitude and direction of femoral malrotation with each technique in 198 anteroposterior view images of the proximal cadaveric femur and osteotomy sites. Based on the results, the main benefit of the QLTP technique over the cortical step sign technique is the ability to determine the direction of femoral malrotation. The QLTP technique was also more accurate in measuring malrotation and had less error. However, the QLTP technique requires additional imaging, and the mean difference in error between the 2 techniques might not be clinically meaningful.

As hospitals seek to control variable expenses, orthopaedic surgeons have come under scrutiny because of relatively high implant costs. We aimed to determine whether feedback to surgeons regarding implant costs results in changes in implant selection.This study was undertaken at a statewide trauma referral center and included 6 fellowship-trained orthopaedic trauma surgeons. A previously implemented implant stewardship program at our institution using a "red-yellow-green" (RYG) implant selection tool classifies 7 commonly used trauma implant constructs based on cost and categorizes each implant as red (used for patient-specific requirements, most expensive), yellow (midrange), and green (preferred vendor, least expensive). The constructs included were femoral intramedullary nail, tibial intramedullary nail, long and short cephalomedullary nails, distal femoral plate, proximal tibial plate, and lower-limb external fixator. Baseline implant usage from the previous year was obtained and provided to each surgeon. Each surgeon received a monthly feedback report containing individual implant utilization and overall ranking.The overall RYG score increased from 68.7 to 79.1 of 100 (P0.001). Three of the 7 implants (tibial and femoral nails and lower-limb external fixation) had significant increases in their RYG scores; implant selections for the other 4 implants were not significantly altered. A decrease of 1.8% (95% confidence interval, 0.4-3.2, P = 0.01) was noted in overall implant costs over the study period.Our intervention resulted in changes in surgeons' implant selections and cost savings. However, surgeons were unwilling to change certain implants despite their being more expensive.

Importance Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. Objective To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. Design, Setting, and Participants This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. Interventions A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. Main Outcomes and Measures The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. Results The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, –3.4%; 95% CI, –6.9% to 0.1%;P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, –3.7%; 95% CI, –6.7% to –0.8%;P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, –1.6% to 2.1%;P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. Conclusions and Relevance Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. Trial Registration ClinicalTrials.gov Identifier:NCT02227446

OBJECTIVE To compare the early pain and functional outcomes of operative fixation versus nonoperative management for minimally displaced complete lateral compression (LC; OTA/AO 61-B1/B2) pelvic fractures. DESIGN Prospective clinical trial. SETTING Two academic trauma centers. PATIENTS Forty-eight adult patients with LC pelvic ring injuries with

Introduction The optimal treatment of elderly patients with an acetabular fracture is unknown. We conducted a prospective clinical trial to compare functional outcomes and reoperation rates in patients older than 60 years with acetabular fracture treated with open reduction and internal fixation (ORIF) alone versus ORIF plus concomitant total hip arthroplasty (ORIF + THA). Our hypothesis was that patients who had ORIF + THA would have better patient reported outcomes and lower reoperation rates postoperatively. Methods Inclusion criteria were patients older than 60 years with acetabular fracture plus at least one of three fracture characteristics: dome impaction, femoral head fracture, or posterior wall component. Eligible patients were operative candidates based on fracture displacement, ambulatory status, and physiological appropriateness. Patients received either ORIF alone or ORIF + THA (accomplished at same surgery through same incision). Outcome measurements included Western Ontario and McMaster Universities Osteoarthritis Index hip score, Short Form 36, Harris Hip Score, and Patient Satisfaction Questionnaire Short Form scores. Additionally, patients were monitored for any unplanned reoperation within 2 years. Results Forty-seven of 165 eligible patients with an average age of 70.7 years were included. The mean Harris Hip Score difference favored ORIF + THA (mean difference, 12.3, [95% confidence interval (CI), -0.3 to 24.9, p = 0.07]). No clinically important differences were detected in any other validated outcome score or patient satisfaction score 1 year after surgery. ORIF + THA decreased the absolute risk of reoperation by 28% (95% CI, 13% to 44%, p Conclusions In patients older than 60 years with an operative displaced acetabular fracture with specific fracture features (dome impaction, femoral head fracture, or posterior wall component), treatment with ORIF + THA resulted in fewer reoperations than treatment with ORIF alone. No differences in patient satisfaction and other validated outcome measures were detected.

The COVID-19 pandemic has presented challenges to healthcare systems, including the cancellation and then staged resumption of elective procedures. The orthopaedic trauma community has continued to provide care to patients with acute musculoskeletal injuries that cannot be delayed in all scenarios. This article summarizes and provides relevant information (orthopaedic trauma service, outpatient fracture clinic, inpatient surgery) to the practicing orthopaedic traumatologist on maximizing outcomes while limiting exposure during the pandemic. LEVEL OF EVIDENCE:: Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Objective To compare the magnitude of knee pain between the suprapatellar (SP) and infrapatellar (IP) approach for tibial nailing in patients who are more than 1 year after injury. Design Retrospective cohort study. Setting Academic Level I trauma center. Patients/participants All tibia fracture patients 18-80 years of age treated with an intramedullary tibial nail during a 5-year period were retrospectively reviewed for inclusion. The surgical approach was determined by surgeon preference, with 3 of the 9 surgeons routinely using the SP approach. The primary outcome was knee pain during kneeling, with secondary assessments comparing knee pain during resting, walking, and the past 24 hours. Intervention Intramedullary nailing of a tibia fracture with either the SP or IP approach. Main outcome measurements Knee pain assessed with the Numeric Rating Scale between 0 and 10. A difference of >1.0 was considered to be clinically meaningful. Results The study group consisted of 262 patients (SP, n = 91; IP, n = 171) with a mean age of 41.4 years (SD = 16.6). The median follow-up was 3.8 years (range: 1.5-7.0). No difference in knee pain during kneeling was detected between the surgical approaches (IP: 3.9, SP 3.8; P = 0.90; mean difference: -0.06, 95% confidence interval, -1 to 0.9). Similarly, no differences were detected in average knee pain scores at rest (IP: 2.0, SP: 2.0; P = 1.00), walking (IP: 2.7, SP 3.0; P = 0.51), or the last 24 hours (IP: 2.6, SP 2.9; P = 0.45). Conclusions In contrast to a study conducted by Sun et al, in which there was a statistical difference in knee pain between the SP and IP surgical approaches, we did not detect any statistical or clinical differences in knee pain between the SP and IP surgical approaches among patients with greater than 12 months of follow-up. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary (IM) nail fixation is a common operative treatment, yet concerns regarding the frequency of complications, such as nonunion, remain. Treatment of tibial shaft fractures remains a challenge, and little evidence of prognostic factors that increase risk of nonunion is available. The aim of this study was to develop a predictive model of tibial shaft fracture nonunion 6 weeks after reamed intramedullary (IM) nail fixation based on commonly collected clinical variables and the radiographic union score for tibial fractures (RUST).A retrospective case-control study was conducted. All tibial shaft fractures treated at our level I trauma center from 2007 to 2014 were retrospectively reviewed. Only patients with follow-up until fracture healing or secondary operation for nonunion were included. Fracture gaps ≥3 mm were excluded. A total of 323 patients were included for study.Infection within 6 weeks of operation, standard RUST, and the Nonunion Risk Determination (NURD) score had statistically significant associations with nonunion (odds ratioor1.0; p0.01). The NURD score was increasingly predictive of nonunion with decreasing RUST. All patients in the high RUST group (RUST ≥ 10), achieved union regardless of NURD score. In the medium RUST group (RUST 6-9), 25% of patients with a NURD score ≥7 experienced nonunion. In the low RUST group (RUST6 or infection within 6 weeks), 69% of patients with a NURD score ≥7 experienced nonunion.Three variables predicted nonunion. Based on these variables, we created a clinical prediction tool of nonunion that could aid in clinical decision making and discussing prognosis with patients.

This study sought to determine (1) whether surgeons can accurately predict functional outcomes of operative fixation of pilon fractures based on injury and initial postoperative radiographs, (2) whether the surgeon's level of experience is associated with the ability to successfully predict outcome, and (3) the association between patients' demographic and clinical characteristics and surgeons' prediction scores. A blinded, randomized provider survey was conducted at a level I trauma center. Seven fellowship-trained orthopedic traumatologists and 4 orthopedic trauma fellows who were blinded to outcome reviewed data regarding 95 pilon fractures in random order. Injury ankle radiographs, initial postoperative fixation radiographs, and brief patient histories were assessed. Midterm follow-up functional outcome scores obtained a mean 4.9 years after surgery were available for all patients. Main outcome measures were Pearson correlation coefficient-assessed functional outcomes and surgeon-predicted outcomes. A mixed-effect model determined the association between patients' characteristics and surgeons' prediction scores. Minimal positive correlation was observed between functional outcomes and prediction scores. No difference was noted between the attending and fellow groups in prediction ability. When surgeons' prediction confidence level was greater than 1 SD above the mean confidence level, correlation between functional outcome and prediction improved, although poor correlation was still observed. AO/OTA type 43C fractures, high-energy mechanisms, and older patient age were characteristics associated with lower prediction scores. Surgeons had poor ability to predict functional outcomes of patients with pilon fractures based on injury and initial postoperative radiographs, and level of experience was not associated with ability to predict outcome. [ Orthopedics . 2020; 43(1): e43–e46.]

To determine the incidence of vacuum phenomenon related intra-articular or subfascial gas found on computer-assisted tomography (CT) scans of closed lower extremity fractures.Retrospective Review.Level I Trauma Center.A total of 153 patients with closed lower extremity fractures.CT scans of identified individuals were reviewed for the presence or absence of gaseous accumulations.The presence or absence of gas on CT.Twenty seven (17.6%) of the 153 fractures were found to have intra-articular or subfascial gas on CT despite clear documentation, indicating a closed injury with no significant skin compromise. Of the intra-articular fractures (OTA/AO 33B/C, 41B/C and 43B/C), 20% (23 of 113) were found to have gas on CT. All cases were associated with fracture of the tibia (P = 0.002).Computed tomography demonstrated the presence of intra-articular or subfascial gas in 17.6% (27/153) of closed lower extremity fractures and in 20% (23/113) of closed intra-articular fractures. The possibility of vacuum phenomenon must be considered when using this imaging modality as the confirmatory test for open intra-articular fracture or traumatic arthrotomy.Level IV.

Objectives To report functional outcomes of displaced acetabular fractures treated nonoperatively in the geriatric patient population. Design Retrospective case series. Setting Two Level I trauma centers. Patients Twenty-seven patients 60 years of age or older who sustained displaced acetabular fractures during an 11-year period. Intervention Nonoperative treatment. Main outcome measurements Primary outcome measurements were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and Short Form 8 (SF-8) scores. Secondary outcome measurements were conversion to open reduction and internal fixation or total hip arthroplasty and 1-year mortality. Results Twenty-six patients completed the WOMAC and SF-8 surveys. The overall WOMAC score was 12.9 ± 15.6 (range, 0-59.4). The average physical SF-8 was 51.1 ± 8.7 (range, 30.4-58.6), and the average mental SF-8 was 55 ± 6.2 (range, 30.4-58.6). The 1-year mortality rate was 24%. Conversion of treatment occurred in 15% of patients. Conclusions Elderly patients with fracture patterns that would qualify for operative treatment in younger healthy patients had surprisingly good outcome scores when treated nonoperatively. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Traumatic and trauma-related amputations represent unfortunate sequelae of severe injury, but should not be viewed as a treatment failure and may represent the best reconstructive option for some patients. Lessons from recent military conflicts have guided the evolution of modern surgical techniques and rehabilitation management of this challenging patient population, and treatment at a specialty center may improve patient outcomes. Despite appropriate management, however, surgical complications remain common and revision surgery is often necessary. Bridge synostosis procedures remain controversial, and clinical equipoise remains regarding their functional benefits. Based on European experience over the last 3 decades, osseointegration has evolved into a viable clinical alternative for patients unable to achieve acceptable function using conventional sockets, and several devices are being developed or tested in the United States. Targeted muscle reinnervation and advanced pattern recognition may dramatically improve the functional potential of many upper extremity amputees, and the procedure may also relieve neuroma-related pain. Furthermore, exciting new research may eventually facilitate haptic feedback and restore useful sensation for amputees. Natural disasters and global terrorism events, in addition to conventional trauma resulting in limb loss, make a working knowledge of current amputation surgical techniques essential to the practicing orthopaedic trauma surgeon.

Background: Our center evaluates all distal radial fractures with traction radiographs before splinting. Although investigations of various imaging modalities to evaluate distal radial fractures have been presented in the literature, to our knowledge the use of traction radiographs has not been well described. We hypothesized that the addition of traction radiographs to standard radiographs increases interobserver and intraobserver reliability for injury descriptions, affects the choice of treatment plan, and decreases the perceived need for computed tomography. Methods: Radiographs for fifty consecutive eligible patients with distal radial fractures that were treated at a level-1 trauma center were used to create two image sets for each patient. Set 1 included injury and splint radiographs, and Set 2 included the images from Set 1 plus traction radiographs. The image sets were stripped of all demographic data and were presented in random order to seven fellowship-trained orthopaedic surgeons. The surgeons independently reviewed each of the 100 image sets and answered ten questions regarding the description and treatment of the injury. Analyses were conducted with kappa statistics to evaluate interobserver reliability. Intraobserver variability was assessed with the McNemar test after adjusting for clustering. Results: Traction radiographs improved interobserver reliability for four of ten questions. With regard to intraobserver variability, responses to two questions were significantly changed. With the addition of traction radiographs, the observation of intra-articular fragments requiring reduction increased from 38.3% to 53.1% (p < 0.05) and the perceived need to order computed tomography for further evaluation decreased from 21.7% to 5.1% (p < 0.001). No other changes reached significance. Conclusion: The addition of traction radiographs appeared to affect surgeons’ interobserver reliability in the evaluation of distal radial fractures. In addition, traction radiographs changed the rate of detection of intra-articular fragments requiring reduction and the perceived need for computed tomography. These data indicate that traction radiographs may provide some of the same information as computed tomographic scans at a lower cost and argue for additional research comparing computed tomographic scans and traction radiographs of the distal part of the radius.

To evaluate the midterm functional outcomes of patients with isolated operatively treated patella fractures.Prospective cohort and retrospective clinical and radiographic assessment.A Level I and Level II trauma center.Two hundred forty-one patients underwent operative intervention for a displaced patella fracture between 1991 and 2007. After appropriate exclusions, 110 patients met criteria. A total of 40 (36%) patients with isolated, unilateral, operatively treated patella fractures with minimum 1-year follow-up agreed to participate in this study and return for functional testing. Mean follow-up was 6.5 years (range, 1.25-17 years).Enrolled patients were treated with one of the following methods: standard tension band with Kirschner wires, tension band through 2 cannulated screws, longitudinal anterior banding with cerclage, or partial patellectomy.All enrolled patients were evaluated with the SF-36 and an injury-specific questionnaire (Knee Injury and Osteoarthritis Outcome Scores) and asked to self-report symptomatic hardware. Patients were also evaluated by physical examination assessing range of motion and Biodex bilateral quadriceps isometric and isokinetic comparisons.The mean normalized SF-36 physical composite score and the mean normalized Knee Injury and Osteoarthritis Outcome Scores subscale scores (pain, 71.7; symptoms, 66.3; activities of daily living, 75.1; sport/recreation, 45.2; quality of life, 49.6) were statistically different (P0.05) from reference population norms. Removal of symptomatic fixation was required in 52% of the patients treated with osteosynthesis, whereas 38% of those with retained fixation self-reported implant-related pain at least some of the time. Eight patients (20%) had an extensor lag greater than 5°. A restricted range of flexion of greater than 5° was noted in 15 patients (38%) and restricted range of extension of greater than 5° was noted in 6 patients (15%). Biodex dynamometric testing revealed a mean isometric extension deficit of 26% between the uninvolved and involved sides for peak torque. Extension power was also tested with an angular velocity of 90°/sec and 180°/sec and mean deficits of 31% and 29% were noted, respectively, when compared with the contralateral extremity.At a mean of 6.5 years after operative treatment for patella fractures, significant symptomatic complaints and functional deficits persist based on validated outcome measures as well as objective physical evaluations. This study fills a void in the literature regarding the functional outcomes of these patients. It also underscores the complexity associated with treating this common fracture and should help guide surgeons to better counsel patients on the expected long-term function after operative treatment of patella fractures.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: A single dose of preemptive gabapentin reduces postoperative pain and postoperative analgesic consumption. However, the optimal dose of preemptive gabapentin remains to be evaluated. METHODS: In this prospective study, we defined the median effective analgesic dose using an up-and-down sequential allocation technique of preemptive gabapentin in 67 patients undergoing elective posterior lumbar spinal fusion. The efficacy of the study drug was assessed by morphine consumption during the first 24 h postoperatively. RESULTS: The median effective analgesic dose (median value and 95% confidence interval) of gabapentin was 21.7 mg/kg (19.9‐23.5 mg/kg). CONCLUSION: Given the large dose of gabapentin needed, further powered studies are warranted to assess side effects. (Anesth Analg 2008;106:305‐8)

The aim of this study was to assess the effect of pre- vs postincisional low-dose iv ketamine on postoperative pain in outpatients scheduled for oral surgery under general anesthesia.Eighty-four patients were randomly assigned to receive intravenously saline before and after surgery in Group 1, ketamine 300 microg x kg(-1) iv before and saline after surgery in Group 2, saline before and ketamine 300 microg x kg(-1) iv after surgery in Group 3. Postoperative analgesia consisted of iv proparacetamol and ketoprofen. Rescue analgesia consisted of nalbuphine 200 microg x kg(-1) iv. Analgesia at home consisted of oral ketoprofen, and acetaminophen with codeine as rescue analgesia. A telephone interview was conducted on the first and second postoperative days.There were no significant differences between groups with respect to pain scores, the number of patients requiring nalbuphine in the postanesthesia care unit (PACU), (36.7%, 38.7%, and 39.5% for Groups 1, 2, and 3 respectively), or nalbuphine consumption in the PACU (66.5 microg x kg(-1) +/- 16.8, 75.9 microg x kg(-1) +/- 17.5, 66.7 microg x kg(-1) +/- 21.6 for Groups 1, 2, and 3 respectively). The number of rescue analgesic tablets taken at home, and time to first request for rescue analgesia, sedation scores, or side-effects were similar amongst groups. No patient required nalbuphine in the ambulatory care unit.There was no benefit to pre-emptive administration of ketamine 300 microg x kg(-1) iv whether administered pre- or postoperatively.

BackgroundVariations in ankle mortise anatomy may be a predisposing factor to ankle instability.HypothesisA posteriorly positioned fibula associated with ankle instability may not be a true pathologic entity but rather the result of measuring off an internally rotated talus.Study DesignCohort study (diagnosis); Level of evidence, 2.MethodsThe authors reviewed 60 ankle computed tomography scans performed on patients from their institution for reasons unrelated to ankle instability. They also reviewed ankle computed tomography scans on 21 patients surgically treated for clinical ankle instability. The position of the fibula in relation to the talar articular surface was calculated and expressed as the axial malleolar index, as described by Scranton et al. They also calculated the intermalleolar index, a new method that references the medial malleolus, not the talus.ResultsUsing the method of Scranton et al, the axial malleolar index in the control and instability patients was similar to values previously described, and there was a significant difference between control and instability patients (P ConclusionThe new method of referencing the medial malleolus assesses fibular position independent of talar rotation. The data, when referencing the medial malleolus, do not show significant variation in fibular position in patients with and without ankle instability.

But Apprecier la valeur de l’electroretinogramme (ERG) pour le diagnostic precoce des differentes formes d’achromatopsie. Introduction L’achromatopsie est une des causes de mal voyance congenitale hereditaire. Elle est evoquee devant un nystagmus, un comportement de cecite ou une photophobie. Seul l’ERG peut permettre d’en affirmer le diagnostic chez le bebe. Patients et methodes Etude retrospective chez 30 patients adresses pour bilan de nystagmus ou de cecite. Ils ont eu un examen ophtalmologique, une etude de la vision des couleurs et un ERG. Celui-ci est realise chez les sujets de plus de 6 ans selon le protocole de l’ISCEV. Chez le petit enfant, un protocole simplifie est utilise. Le stimulateur est un flash a diodes electroluminescentes. Un ERG de controle est effectue a distance. Resultats La morphologie de l’ERG est identique chez les enfants et les adultes. Elle est en faveur d’une achromatopsie complete : les composantes scotopiques obtenues apres adaptation a l’obscurite sont normales alors que les composantes photopiques enregistrees apres une adaptation a la lumiere suffisante pour inhiber les bâtonnets ne sont pas detectables. Les tests de vision des couleurs confirment ce diagnostic ; pourtant certains patients denomment correctement la plupart les couleurs. Conclusion Les procedures d’ERG que nous utilisons chez le bebe sont fiables pour diagnostiquer une achromatopsie. Il n’est pas possible d’affirmer qu’ils le sont pour differencier une achromatopsie complete d’une achromatopsie incomplete.

In this study, we assessed the reliability of the inguinal crease and femoral artery as anatomic landmarks for the anterior approach to the sciatic nerve and determined the optimal position of the leg during this approach. An imaging study was conducted before the clinical study. The sciatic nerve was located twice in 20 patients undergoing ankle or foot surgery, once with the leg in the neutral position and once with the leg in the externally rotated position. The patient was lying supine. A 22-gauge, 150-mm insulated b-beveled needle connected to a nerve stimulator was inserted 2.5 cm distal to the inguinal crease and 2.5 cm medial to the femoral artery and was directed posteriorly and laterally with a 10°–15° angle relative to the vertical plane. The sciatic nerve was located in all patients at a depth of 10.6 1.8 cm when the leg was in the neutral position and 10.4 1.5 cm when the leg was in the externally rotated position (not significant). In the neutral position and in the externally rotated position, the time needed to identify anatomic landmarks was 28 15 s and 26 14 s, respectively (not significant), and the time needed to locate the sciatic nerve was 79 53 s and 46 25 s( P 0.006), respectively. We conclude that the inguinal crease and femoral artery are reliable and effective anatomic landmarks for the anterior approach to the sciatic nerve and that the optimal position of the leg is the externally rotated position. (Anesth Analg 2002;95:214 –8) B lockade of the sciatic nerve may be used to provide anesthesia to the foot and the lower extremity to the knee. The sciatic nerve can be approached at the pelvic level posteriorly, anteriorly, or laterally. The anterior approach to the sciatic nerve is performed with the patient remaining in the supine position and can therefore be advantageous in situations where patient mobilization is limited. The anterior approach to the sciatic nerve was first described by Beck (1) in 1963. Landmarks for the technique included identification of the greater trochanter, which can be difficult in obese patients or painful in trauma patients. Chelly and Delaunay (2) described a new anterior approach using easy-to-identify landmarks. Nevertheless, both techniques require drawing lines between bony landmarks and perpendicular dissectors. The inguinal crease and femoral artery can be easily identified, even in obese patients. This study was designed to prospectively evaluate the efficacy of a new anterior approach to the sciatic nerve by using the inguinal crease and femoral artery as landmarks. We also tried to determine whether the best position of the leg for the anterior approach technique was the neutral or the externally rotated position. The study was conducted in two parts. The clinical study was conducted after an imaging study designed to determine the optimal puncture site and needle direction.

Intracompartmental pressure measurements are frequently used in the diagnosis of compartment syndrome, particularly in patients with equivocal or limited physical examination findings. Little clinical work has been done to validate the clinical use of intracompartmental pressures or identify associated false-positive rates. We hypothesized that diagnosis of compartment syndrome based on one-time pressure measurements alone is associated with a high false-positive rate.Forty-eight consecutive patients with tibial shaft fractures who were not suspected of having compartment syndrome based on physical examinations were prospectively enrolled. Pressure measurements were obtained in all four compartments at a single point in time immediately after induction of anesthesia using a pressure-monitoring device. Preoperative and intraoperative blood pressure measurements were recorded. The same standardized examination was performed by the attending surgeon preoperatively, postoperatively, and during clinical follow-up for 6 months to assess clinical evidence of acute or late compartment syndrome.No clinical evidence of compartment syndrome was observed postoperatively or during follow-up until 6 months after injury. Using the accepted criteria of delta P of 30 mm Hg from preoperative diastolic blood pressure, 35% of cases (n = 16; 95% confidence interval, 21.5-48.5%) met criteria for compartment syndrome. Raising the threshold to delta P of 20 mm Hg reduced the false-positive rate to 24% (n = 11; 95% confidence interval, 11.1-34.9%). Twenty-two percent (n = 10; 95% confidence interval, 9.5-32.5%) exceeded absolute pressure of 45 mm Hg.A 35% false-positive rate was found for the diagnosis of compartment syndrome in patients with tibial shaft fractures who were not thought to have compartment syndrome by using currently accepted criteria for diagnosis based solely on one-time compartment pressure measurements. Our data suggest that reliance on one-time intracompartmental pressure measurements can overestimate the rate of compartment syndrome and raise concern regarding unnecessary fasciotomies.Diagnostic study, level II.

Orthopedic procedures represent a large expense to the Medicare program, and costs of implantable medical devices account for a large proportion of those procedures’ costs. Physicians have been encouraged to consider costs in the selection of devices, but several factors make acquiring information about costs difficult. To assess physicians’ levels of knowledge about costs, we asked orthopedic attending physicians and residents at seven academic medical centers to estimate the costs of thirteen commonly used orthopedic devices between December 2012 and March 2013. The actual cost of each device was determined at each institution; estimates within 20 percent of the actual cost were considered correct. Among the 503 physicians who completed our survey, attending physicians correctly estimated the cost of the device 21 percent of the time, and residents did so 17 percent of the time. Thirty-six percent of physicians and 75 percent of residents rated their knowledge of device costs “below average” or “poor.” However, more than 80 percent of all respondents indicated that cost should be “moderately,” “very,” or “extremely” important in the device selection process. Surgeons need increased access to information on the relative prices of devices and should be incentivized to participate in cost-containment efforts.

Objective - Visual evoked potentials (VEPs) are a very useful tool in diagnosis of multiple sclerosis (MS). Nevertheless, in some cases of the disease, VEPs are normal. The aim of this study was to evaluate the diagnostic value of focal checkerboard reversal stimulation based on opto-acoustic modulation generated by a scanning laser ophthalmoscope (SLO) in patients whose standard neuro-ophthalmological work-up was normal. Methods - We prospectively studied 185 MS patients. In this cohort we found 30 patients with definite MS and normal neuro-ophthalmological work-up and we studied the diagnostic yield of focal visual stimulation in these patients. We performed focal SLO-elicited VEPs with two different spatial distributions: a central 8 x 8 degrees square field and a central 8 x 8 degrees exclusion square. The results were analysed in terms of age of the patient, course of the disease, and disability evaluated on the Expanded Disability Status Scale (EDSS). Results - Mean latencies of focal VEPs were increased in MS patients compared to controls. In MS, focal stimulation allowed dysfunction of the visual system to be detected in 50% of patients who have been classified as normal according to conventional VEPs. VEP abnormalities were found to be correlated with the EDSS score (P

One hundred and 16 patients contributed to an analysis of the impact of the consequences of severe haemophilia A or B (factor levels < 2%) on orthopaedic status, resources consumed in relation to this status and resultant cost, and quality of life as perceived by the patient, using the MOS 36-Item-Short-Form Health Survey (SF-36). This French cross-sectional study involved outpatients regularly attending a haemophilia treatment centre. Data were collected retrospectively over a period of 1 year by the physician of the haemophilia treatment centre. Patients had a mean age of 23, and consisted of 50% students, 25% salaried workers, 17.2% with no professional activity and 7.8% physically impaired; 82.8% of them had type A haemophilia. Mean pain score was 2.5 per patient for the six main joints; 7.7 for the clinical score and 18.8 for the radiological score, with a mean number of bleeds of 16.3 per year per patient. During the year prior to inclusion, and because of their orthopaedic status, 22.4% of patients were hospitalized, 76.7% attended for an outpatient visit and 76.7% required at least one special investigation; 97.4% received replacement therapy, 41.4% required treatment for joint pain and 42.2% orthopaedic equipment. The less affected dimensions were the physical function (76.8 +/- 22. 2) and the social relations (76.1 +/- 23.1). Least good quality of life scores concerned the pain (60.2 +/- 25.2), perception of general health (59.3 +/- 23.1) and vitality (57.8 +/- 19.5) dimensions. The age was a discriminant criterion since quality of life was better in patients of the 18-23 age group for five dimensions. Mean annual treatment costs of a patient with severe haemophilia were determined as 425 762 French francs ($73 029). Loss of production was estimated at a mean of 4609 French francs ($791) per active patient over the course of the year. Results showed indirect evidence of the usefulness of early home treatment.

The aim of this study was to investigate in a large population of patients with obstructive sleep apnoea and on long-term treatment with continuous positive airway pressure (CPAP) the patients' perception of symptomatic improvement, side-effects and quality of life. Questionnaires were mailed via local respiratory homecare associations to 5,339 French patients who had been treated at home for at least 6 months with CPAP machines and who continued their treatment. In total, 3,225 questionnaires were analysable. More than 80% of the responding patients reported that CPAP treatment had greatly improved their symptoms. Despite discomfort related to nasal problems and excess noise from the blower, the mean rate of use for the whole population was 6 h 36 min+/-2 h 15 min. The perceived health evaluated by the Nottingham Health Profile was good (mean score

This article reports on the economic, social and quality-of-life issues relating to hypertension. Although it does not claim to be a comprehensive review of the many studies available in this field, it does attempt to highlight the main areas of interest. From both a macro- and a micro-economic viewpoint, hypertension and its associated cardiovascular and renal diseases are characterized by high costs. Treatment costs can, for certain persons, represent a considerable obstacle and result in limited access to any form of care. Nevertheless, providing access to care does not necessarily ensure that an individual patient receives effective treatment. Socioeconomic factors can have varying degrees of influence on the success of any therapy, and can affect, for example, treatment compliance. An individual's awareness of his/her hypertension (the labelling effect) and the initiation of any form of long term treatment can have specific effects on quality of life; yet, in order to ensure adequate patient compliance, treatment should not impair quality of life. Evaluation of quality of life depends not only on the dimensions under investigation but also on the use of reliable, legitimate, sensitive and previously validated questionnaires. The use of such questionnaires has enabled the complex links between quality of life and blood pressure to be recognised. This in turn has led to an assessment of various drug treatments. Results would appear to indicate that hypertension and its treatment do indeed affect patients' quality of life, a factor that ultimately influences the approach to disease management and the choice of long term treatment.

Resume Le suivi des bradyzoites de T gondii dans les kystes explique, chez l'enfant atteint de toxoplasmose congenitale, l'existence de poussees cliniques evolutives et de rebonds serologiques. L'attitude du praticien demeure mal definite vis-a-vis de ces manifestations secondaires des oxoplasmoses congenitales. Patients et methodes. - Une cohorte de 63 enfants contamines in utero par T gondii a ete suivie durant les 2 premieres annees de vie au CHRU de Lille. Il a ete possible, pour chaque enfant, de preciser les traitements administres avant et apres la naissance et de suivre chaque trimestre l'etat clinique, le fond d'œil ainsi que l'evolution des anticorps specifiques. Des techniques specialement adaptees a l'âge de ces enfants ont ete utilisees pour quantifier les IgG et pour detecter les IgM et les IgA specifiques de T gondii Resultats. - Alors que 76 rebonds serologiques etaient observes chez 55 enfants (87% de la cohorte), seules cinq poussees cliniques evolutives dont quatre precedees d'un rebond serologique etaient identifiees. Les rebonds serologiques ont essentiellement concerne les IgG specifiques (96 %), plus rarement les IgM (47 %) et les IgA (60 %). Discussion. - L'etude de l'influence du traitement sur l'apparition des poussees cliniques evolutives et des rebonds serologiques a montre que, par rapport a la spiramycine, l'administration associee de sulfamides et de pyrimethamine diminuait le nombre des rebonds. Ainsi, la prescription d'un traitement associatif durant la grossesse diminue le nombre des rebonds biocliniques durant la premiere annee d'une maniere plus importante que la spiramycine (p Conclusion. - L'apparition successive de rebonds serologiques, puis de poussees cliniques evolutives, ainsi que l'activite des trailements sur la frequence de ces manifestations permettent de considerer ces rebonds biocliniques comme d'authentiques temoins d'une multiplication parasitaire recente. La recrudescence de ces rebonds apres l'arret des traitements associatifs rend necessaire l'evaluation de l'efficacite des traitements associatifs continus.

Resume L'efficacite, la tolerance et les couts de 2 strategies therapeutiques de la prise en charge de la pyelonephrite aigue primitive de l'enfant (PNA) ont ete evalues dans cette etude randomisee, multicentrique, conduite dans 28 services de Pediatrie repartis en France. La PNA etait diagnostiquee chez des enfants âges de 6 mois a 10 ans, presentant un premier episode defini par une fievre 38°C, une bacteriurie significative, une elevation des polynucleaires neutrophiles et de la CRP et traites en milieu hospitalier. Apres 4 jours de bitherapie parenterale par l'association ceftriaxone-netilmicine, les enfants etaient randomises pour recevoir pendant 6 jours soit du cefixime per os 4 mg/kg 2 fois par jour, soit de la ceftriaxone 50 mg/kg par voie IM ou IV en une injection quotidienne. Le critere d'evaluation principal etait la guerison clinique avec sterilisation des urines a J12, et a J20-30 pour les enfants gueris a J12 (48 h apres la fin du traitement de relais). L'evaluation des couts etait faite par la valorisation des couts directs et indirects de chaque strategie. Sur les 128 enfants evalues, 63 ont ete traites par cefixime et 65 par ceftriaxone. Les resultats obtenus ont montre l'equivalence en fin de traitement et a distance des 2 strategies: le pourcentage de succes a J12 et J20-30 a ete de 98 % et 100 % pour cefixime et de 100 % et 96 % pour ceftriaxone. L'incidence d'effets indesirables de 13 % et 11 % pour cefixime et ceftriaxone respectivement. E. coli a ete le germe le plus souvent isole dans les deux groupes (93 %), avec un taux de resistance a l'amoxicilline et a l'association amoxicillineacide clavulanique de 45 % et 24 % respectivement. Aucune souche n'etait resistante aux cephalosporines de troisieme generation. Les couts medicaux directs ont ete significativement plus eleves dans le groupe traite par ceftriaxone avec 3 545 Francs (2 478–4 673 F) versus 513 Francs (176–896 F) dans le groupe cefixime. Aucune difference n'a ete observee concernant les couts indirects des deux strategies.

Resume Une etude sur l'utilisation de la ceftriaxone en pratique ambulatoire a ete realisee an cours de l'hiver 1994–95, associant le regime d'Assurance Maladie des Professions Independantes (AMPI), la Mutualite Sociale Agricole (MSA), un centre de recherche et le laboratoire commercialisant la molecule. 972 ordonnances comportant une prescription de ceftriaxone, presentees au remboursement sur une periode de 15 jours, ont ete analysees. Ces prescriptions ont ete documentees par l'envoi d'un questionnaire aux medecins ayant initie le traitement par ceftriaxone. Le bon usage du produit a ete defini par rapport aux textes des references disponibles : Autorisation de Mise sur le Marche, Fiche de Transparence et References Medicales Opposables. Un arbre de decision a ete elabore sur la base de ces criteres. Il a permis de repartir les prescriptions de ceftriaxone dans 6 modes de classements, lies principalement a la nature de l'infection et a l'existence de facteurs de risque ou de severite et aux circonstances de prescription : un premier mode, correspondant aux cas explicitement prevus par l'AMM, deux modes rassemblant des prescriptions liees a des infections entrant implicitement dans le champ de l'AMM, un mode regroupant des prescriptions qui, apres examen individuel par un expert infectiologue, ont ete considerees comme appropriees; un mode correspondant a des prescriptions non appropriees au regard des references retenues; un mode rassemblant les cas pour lesquels il n'a pas ete possible de statuer. Par definition, les 4 premiers modes cites ci-dessus regroupent les prescriptions qui ont ete considerees comme appropriees au regard des references retenues. La population traitee etait âgee (71,5 ans en moyenne). En moyenne, la posologie prescrite etait de 1,02 g en 1,03 injection par jour durant 6,6 jours. 77,6 % des infections concernaient les voies respiratoires basses, 7,9 % les voies respiratoires superieures, 7,7 % les voies urinaires, 6,8 % d'autres infections. Dans 20,4 % des cas, le patient presentait plus de 2 infections. L'analyse des prescriptions par rapport au bon usage a montre qu'au total, 78 % des prescriptions de ceftriaxone etaient appropriees au regard des references retenues.

Insertion and maintenance of an interscalene catheter is technically challenging using lateral or anterior approaches. We report a technique to provide continuous brachial plexus blockade through a 48-h infusion of ropivacaine 0.1% (5 mL/h with a 5 mL bolus dose, 20-min lockout interval) using a catheter inserted with cannula-over-needle technique on the posterior side of the neck in 120 patients undergoing shoulder surgery. All catheters were successfully placed. There were no technical complications (impossibility to thread catheter, accidental vascular, epidural or subarachnoid location), catheter dislodgment, or analgesic solution leakage. Dysphonia, Horner's syndrome, and difficulty breathing were observed in 12 patients, four patients, and one patient, respectively. One patient complained of minor paresthesia that spontaneously resolved. Three patients complained of cervical pain. Pain scores as well as ropivacaine requirement via a patient-controlled analgesia device were low. Evaluation of acute and nonacute complications in a large-size study is needed to compare efficacy and safety of this approach with existing techniques.

Resume L'evolution a long terme des etats vegetatifs (EV) post-traumatiques est mal connue. Trois sortes de donnees ont ete recueillies pour 522 patients en EV, 1 mois apres un traumatisme crânien: donnees pretraumatiques; donnees initiales, recueillies durant les deux premieres semaines suivant le traumatisme; donnees secondaires, recueillies 1 mois ou plus apres le traumatisme. Des relations statistiques ont ete recherchees entre ces donnees et l'evolution 1 an apres le traumatisme, en accord avec l'echelle de l'evolution de Glasgow. Certaines donnees secondaires apparaissent comme des facteurs pronostiques essentiels: clignement des yeux a la menace; complications; dilatation ventriculaire; score moteur (Glasgow Coma Score); mouvements oculaires spontanes. Les donnees pretraumatiques interviennent ensuite: âge; deficiences anterieures. Les autres donnees (et plus particulierement les donnees initiales) semblent posseder une influence plus faible sur l'evolution.

A survey of studies was used to investigate the economic repercussions of arterial disease; these repercussions included the cost of the disease and its management, and cost/efficacy, cost/utility, and cost/benefit studies of preventive, diagnostic, and therapeutic strategies. The study presented is an evaluation of the socio-economic consequences of peripheral occlusive arterial disease of the lower limbs (POADLL). The cost of health care was measured by means of a prospective 6-month study of 85 patients recruited in 6 centers. The average cost over the 6-month period was 15,735 FF (1991 francs) ($2,760 U.S.). The 85 patients were classified by age, sex, risk factors, concomitant disease, and how the illness was managed, notably in terms of hospitalization and vascular surgery. The four-group classification was used to calculate an annual management cost for POADLL, which ranged from 9,500 FF ($1,667 U.S.) for a stage II patient (mean age, 66 years) with no major risk factors and not presenting any complication requiring admission to hospital, to 35,000 FF ($6,140 U.S.) for patients (mean age, 62 years) who presented major risk factors and who required vascular surgery during the year.

Background and Objectives The posterior approach to the brachial plexus remains underused. We assessed the clinical effectiveness of this technique for shoulder surgery. Methods One hundred eighty-seven consecutive patients scheduled to undergo shoulder surgery were assessed after a single-injection nerve-stimulation technique using ropivacaine 0.75%. Sensory and motor block was evaluated in the distribution area of each terminal branch of the brachial plexus every 10 minutes for 30 minutes. Postoperative analgesia was evaluated at regular time intervals at rest and with passive movement, up to 24 hours postoperatively. Results The brachial plexus was reached at a depth of 6.5 ± 0.9 cm. One attempt was sufficient in 85% of patients. Neck pain during insertion of the needle was encountered in 6 (3%; 95% confidence interval [CI], 0.7%-5.6%) patients. Thirty minutes after ropivacaine injection, the axillary, radial, median, musculocutaneous, and ulnar nerves were anesthetized in 100%, 100%, 97%, 96%, and 68% of cases, respectively. The success rate of the block was 98%. Postoperative analgesia was satisfactory in 97% of patients up to 12 hours after the initial injection. Dysphonia and Horner’s syndrome were observed in 14 (7%; 95% CI, 3.7%-11.2%) and 12 (6%; 95% CI, 2.9%-9.9%) patients, respectively. One patient (0.5%; 95% CI, 0%-1.5%) had documented hemidiaphragmatic paresis. No complication was noted during the 3-month follow-up period. Conclusions This study reports the clinical effectiveness of the single-injection nerve-stimulation technique for the brachial plexus block via the posterior approach in patients undergoing shoulder surgery. It appears to be effective, relatively safe, and well tolerated.

The lack of tools to manipulate nanoscale objects is a major obstacle to fabricating and testing nanodevices. Optical tweezers are a promising tool for nanomanufacturing, but the efficiency of optical tweezer manufacturing depends on the number of trapping beams available. Micro optics technology offers the opportunity to significantly increase the number of trapping beams without a significant increase of the cost or size of the optics. Here we report on the sensors, optical circuit and the experimental work to control an array of laser beams generated by a single laser diode, for optical-tweezer-based nanomanufacturing. Our array of laser beams is generated by an array of servo controlled scanning dual-axis micro-mirrors. Capacitor electrodes underneath the micro-mirror plates provide electrostatic actuation, which allows control of the micro-mirror position. With proper reflecting surfaces it is possible to control the impact angle of the individual laser beams onto the micro-nano-particles, thus generating an optical beam gripper effect.

A comparison between the cost of identification and care of patients with phenylketonuria (PKU) and congenital hypothyroidism (CH) and the expenditure for the care of untreated retarded patients has been established on the basis of the activity of the Nord-Pas-de-Calais regional screening centre and of interviews with patients' families. The analysis yields a benefit-cost ratio of 6.6 for PKU and 13.8 for CH prophylaxis. However, cost-benefit varies depending on the economic partner, i.e. the patient's family, Social Security or Administration.

We read with interest the article by Kwok et al. (1). The authors demonstrated that small dose of the N-methyl-d-aspartic acid (NMDA) receptor antagonist ketamine provides preemptive analgesia in patients undergoing gynecologic laparoscopic surgery. There are conflicting results in the literature concerning preemptive effect of ketamine. Studies have documented a preemptive effect (2–5) and others have not (6–10). The efficacy of ketamine is linked to activation of NMDA receptors of the dorsal horn of the spinal cord. In case of adequate perioperative analgesia, NMDA receptors activation is likely to be suppressed and ketamine administration useless. In the studies that have documented a preemptive effect of ketamine (2–5), the perioperative opioid analgesia is questionable and likely to have induced intraoperative activation of NMDA receptors. In the study of Kwok et al. (1) patients were administered an average total dose of 2 g/kg of fentanyl. Surgery lasted more than 60 min. Given the pharmacokinetics of fentanyl, we can wonder whether intraoperative analgesia was adequate, even in these minimally invasive surgery procedures. Inadequate analgesia might have, therefore, led to NMDA receptor activation and subsequent positive action of ketamine. The real challenge, however, in the clinical setting might not be to use the least amount of analgesic drug but to minimize long-term complications and occurrence of chronic pain syndromes. The study of Kwok et al. would have gained in interest if they had more focused on the long-term follow-up of the patients, using clinical assessment of allodynia and hyperalgesia.