**16. Postoperative analgesic management**

Proper management of acute post-operative pain after arthroscopic shoulder surgery enables patients to be discharged earlier, reducing the rate of rehospitalization, and facilitating early rehabilitation and recovery. Optimal pain control also includes evaluating the patient's physical and psychological situation, altered as a result of the surgery. As indicated, pain management should commence in the pre-operative period, while the use of neuromodulator drugs, such as gabapentin/pregabaline, can reduce post-operative pain and the need for analgesics after arthroscopic surgery for ruptured rotator cuff (17). In the intra-operative period, pain can be controlled by administering the appropriate analgesic anesthetic technique, both in terms of the type of approach and the local anesthetics used, as well as the intra-articular drugs administered (18). Post-operative management includes oral/IV analgesics, heated iv fluid and if necessary, the use of narcotics or continuous perineural infusion techniques (19).

Multiple studies have compared different Different therapeutic strategies have often been compared, including single dose perineural infiltration and continuous infusion techniques (20), technical perineural analgesia versus intravenous patient controlled analgesia, perineural versus intra-articular analgesia (21,22), etc. The pPain is usually worst during the first 48h and it is influenced by many factors apart from the surgery (23). In our experience, paracetamol administration in association with continuous intravenous infusion of NSAIDs scheduled during the first 48h successfully reduces post-operative pain, without provoking any serious side effects. Open shoulder surgery or failure in the regional block can require post-operative treatment with morphine by patient-controlled analgesia (PCA). The control and monitoring of these patients by the acute in-patient Pain Unit, or through telephone follow-up for out-patients, is very important to ensure adequate pain control and to optimize the needs of these patients. Different protocols can be used to adapt the therapy to the patient's specific characteristics, and to diagnose and treat the different potential side effects.

Particular attention should be paid to patient ventilation, which can be compromised by previous handling of the airways or by diffusion of the liquid infused into the neck joint if the lateral decubitus position was used. Check the temperature of the patient as it may fall, ensure that the patient is maintained warm and that warm fluids are infused. It is possible that post-operartive nausea and vomiting may occur, especially when the blockade is associated with general anesthesia. Although rare, we can not forget the possibility of delayed onset neurotoxicity or cardiotoxicity, especially in elderly patients.

### **17. References**

62 Modern Arthroscopy

Given the possible occurrence of pneumothorax in the hours after the blockade, this

Contraindicated for use in patients with respiratory disease, contralateral recurrent

 It may be necessary to perform a concomitant intercostobrachial nerve block if there is prolonged use of a tourniquet. This nerve root emerges from D2-D3 and it is responsible for part of the sensitivity in the inside of the arm, lying over the artery in

Proper management of acute post-operative pain after arthroscopic shoulder surgery enables patients to be discharged earlier, reducing the rate of rehospitalization, and facilitating early rehabilitation and recovery. Optimal pain control also includes evaluating the patient's physical and psychological situation, altered as a result of the surgery. As indicated, pain management should commence in the pre-operative period, while the use of neuromodulator drugs, such as gabapentin/pregabaline, can reduce post-operative pain and the need for analgesics after arthroscopic surgery for ruptured rotator cuff (17). In the intra-operative period, pain can be controlled by administering the appropriate analgesic anesthetic technique, both in terms of the type of approach and the local anesthetics used, as well as the intra-articular drugs administered (18). Post-operative management includes oral/IV analgesics, heated iv fluid and if necessary, the use of narcotics or continuous

Multiple studies have compared different Different therapeutic strategies have often been compared, including single dose perineural infiltration and continuous infusion techniques (20), technical perineural analgesia versus intravenous patient controlled analgesia, perineural versus intra-articular analgesia (21,22), etc. The pPain is usually worst during the first 48h and it is influenced by many factors apart from the surgery (23). In our experience, paracetamol administration in association with continuous intravenous infusion of NSAIDs scheduled during the first 48h successfully reduces post-operative pain, without provoking any serious side effects. Open shoulder surgery or failure in the regional block can require post-operative treatment with morphine by patient-controlled analgesia (PCA). The control and monitoring of these patients by the acute in-patient Pain Unit, or through telephone follow-up for out-patients, is very important to ensure adequate pain control and to optimize the needs of these patients. Different protocols can be used to adapt the therapy to the patient's specific characteristics, and to diagnose and treat the different potential side

Particular attention should be paid to patient ventilation, which can be compromised by previous handling of the airways or by diffusion of the liquid infused into the neck joint if the lateral decubitus position was used. Check the temperature of the patient as it may fall, ensure that the patient is maintained warm and that warm fluids are infused. It is possible that post-operartive nausea and vomiting may occur, especially when the blockade is associated with general anesthesia. Although rare, we can not forget the possibility of

delayed onset neurotoxicity or cardiotoxicity, especially in elderly patients.

delayed Delayed neurological dysfunction: usually transient.

may not be a good option for outpatient surgery.

Other considerations and peculiarities:

paralysis and impaired hemostasis.

the subcutaneous tissue of the axilla.

perineural infusion techniques (19).

effects.

**16. Postoperative analgesic management** 


**1. Introduction** 

Fernandez, 2002; Willis et al., 2006).

effectiveness for the treatment of DRF.

**2. Technique** 

**4** 

*Japan* 

**Arthroscopic Treatment of** 

Distal radius fracture (DRF) is one of the most common traumatic events for the hand surgeon to treat. Numerous surgical procedures have been described for this fracture (Ruch et al., 2004); however, the ideal method of surgical management is still controversial. The latest development of a volar locking plate fixation markedly changed the treatment of DRF (Chen & Jupiter, 2007; Chung et al., 2006). Volar locking plate fixation creates a more rigid mechanical construct and allows early rehabilitation that can be initiated with the goal of an improved functional outcome; therefore, volar locking plate fixation currently has widespread popularity, even for dorsally displaced intraarticular fracture (Orbay &

The functional outcome of the treatment of DRF is considered to be affected by extraarticular alignment, anatomical reduction of the articular surface, intraarticular soft tissue injuries and postoperative complications. Wrist arthroscopy is currently recognized as an important adjunctive procedure in the management of DRF (Doi et al., 1999; Freeland & Geissler, 2000; Ruch et al., 2004). This is because arthroscopically assisted reduction and internal fixation of DRF cause minimal surgical intervention and provide not only excellent visualization of the joint surface for anatomical restoration of articular fragments but evaluate and treat intraarticular soft tissue injuries. Although it is better used in conjunction with percutaneous pinning and external fixation, wrist arthroscopy becomes problematic when plate fixation is performed because vertical traction has to be both applied and released during surgery; therefore, a plate presetting arthroscopic reduction technique (PART) using a volar locking plate has been developed, that can simplify the combination of plating and arthroscopy (Abe et al., 2008). PART can also be performed with minimal skin incision and is less invasive. This chapter will describe the procedure of PART and its

All patients with DRF were managed initially with closed reduction and casting at the first visit to our clinic. Consecutive patients with inadequate reduction or re-displacement underwent arthroscopic reduction and volar locking plate fixation. Our surgical indications regarding radiological assessment included less than -10 degrees or over 20 degrees of

palmar tilt, and over 2 mm of ulnar plus variance compared to the normal side.

**Distal Radius Fractures** 

Yukio Abe and Yasuhiro Tominaga *Saiseikai Shimonoseki General Hospital* 

