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By T. Denpok. Antioch College.

The role of and prevent fibrin thrombi formation in periarticular the bone scan remains controversial: isolated articular tissues (Gosh viagra soft 100 mg without prescription, 1992; Bucci generic viagra soft 50mg line, 1994; Muller-Fassbender surface defects that do not penetrate subchondral bone et al, 1994). Recent studies indicate that pain, joint may not be identified by bone scan. Arthroscopy con- line tenderness, range of motion, and walking speed tinues to remain the gold standard for the diagnosis of may be improved with these medications (Barclay, articular cartilage injuries. Tsourounis, and McGart, 1998; DaCamara and The Outerbridge classification system (Outerbridge, Dowless, 1998). However, there are no clinical data 1961) was initially developed for macroscopic grad- showing that these oral agents affect the formation of ing of chondromalacia patellae and has since been cartilage (Tomford, 2000). A recent modifica- with high-molecular weight hyaluronans remains an tion by the International Cartilage Repair Society option despite the lack of well-controlled studies (ICRS) (Brittberg, 2000; Brittberg and Peterson, demonstrating efficacy. Suggested indications for referral to an orthopedic surgeon with expertise in cartilage NONSURGICAL MANAGEMENT restoration techniques are presented in Table 9-5. Acute motion loss Gross deformity Traditional methods for treatment of chondral lesions Acute neurovascular deficit include the judicious use of nonsteroidal anti-inflam- Mechanical symptoms (catching, locking, sensation of a loose body) matory drugs combined with activity modification. Failed nonsurgical management greater than 3 months in duration Oral chondroprotective agents such as glucosamine Repeated giving way or complaints of instability 50 SECTION 1 GENERAL CONSIDERATIONS IN SPORTS MEDICINE SURGICAL MANAGEMENT quality and volume of repair tissue (fibrocartilage) is variable. These procedures are used in low demand patients with larger lesions (>2 cm2) or in higher Various surgical modalities exist for the treatment of demand patients with smaller lesions (<2 cm2). The goals are to reduce symptoms, and abrasion arthroplasty for several reasons: (1) it is improve joint congruence by restoring the articular sur- less destructive to the subchondral bone because it cre- face with the most normal tissue (i. Postoperative rehabilitation PALLIATIVE consists of nonweight bearing for 6 to 8 weeks and may include continuous passive motion (CPM) to improve Arthroscopic debridement and lavage is used to the extent and quality of the repair tissue. As MSTs are remove degenerative debris, cytokines, and proteases low-cost and relatively low-morbidity procedures, they that may contribute to cartilage breakdown. It is ide- remain the mainstay for the initial management of ally indicated in the patient with defect area less than small chondral lesions. Postoperative rehabilitation involves weight- bearing as tolerated and early strengthening exercises. RESTORATIVE In the absence of meniscal pathology, the results fol- lowing arthroscopic debridement are at best guarded. This restorative procedure results in the depth of chondrocyte death and cellular necrosis in hyaline-like cartilage which is believed to be superior the treated area and thus remains investigational. Postoperative reha- bilitation entails aggressive CPM and nonweight bear- ing for 6 weeks with a gradual increase to full-weight REPARATIVE bearing from 6 to 12 weeks. ACI is a costly procedure with a relatively lengthy recovery period and is most Marrow stimulating techniques (MST—microfracture, often used as a secondary procedure for the treatment abrasion arthroplasty, and subchondral drilling) involve of medium to larger focal chondral defects (>2 cm2). The resulting and articular cartilage which can be obtained from the TABLE 9-6 Surgical Management of Chondral Lesions PROCEDURE INDICATIONS OUTCOME Arthroscopic debridement Minimal symptoms, short-term relief Palliative and lavage Thermal chondroplasty Partial thickness defects, investigational Palliative (laser, radiofrequency energy) Marrow stimulating techniques Smaller lesions, persistent pain Reparative Autologous chondrocyte Small and large lesions with or without Restorative implantation subchondral bone loss Osteochondral autograft Smaller lesions, persistent pain Restorative Osteochondral allograft Larger lesions with subchondral bone loss Restorative CHAPTER 9 ARTICULAR CARTILAGE INJURY 51 TABLE 9-7 Results of Arthroscopic Debridement and Lavage AUTHOR N MEAN FOLLOW-UP RESULTS Owens et al, 2002 19 patients 24 months Fulkerson score 12 mos – 80. Osteochondral allograft can be used to treat larger ing the three-dimensional surface contour. Tissue matching and immunologic sup- using the patient’s own tissue; however, the lim- pression are unnecessary as the allograft tissue is ited amount of donor tissue confines this tech- avascular and alymphatic.

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Analgesia may also be the result of the sedative and INTRODUCTION muscle relaxant properties of these agents Hydroxyzine is the most widely used agent and is the Some drugs are known to result in analgesia in certain only antihistamine that has been proven to have intrin- pain syndromes purchase 100mg viagra soft fast delivery. Direct effect on skeletal muscle fiber (dantrolene purchase 100mg viagra soft mastercard, methocarbamol) Polysynaptic reflexes (benzodiazepines, baclofen, CNS STIMULANTS tizanidine, other muscle relaxants) Descending facilitory systems (benzodiazepines, AMPHETAMINES other muscle relaxants) Amphetamines are often co-administered with the opioids to treat opioid-induced sedation. CAFFEINE DANTROLENE Caffeine enhances the analgesic effect of aspirin and Dantrolene is a potent antispasmodic that dissociates acetaminophen. CORTICOSTEROIDS Dantrolene is indicated for the treatment of spasticity secondary to spinal cord injury. MUSCLE RELAXANTS Because long-term use is controversial, diazepam should be used in selected cases only. It decreases excitability of the motor end- controversial and the efficacy studies are less con- plate. TIZANIDINE Because of the minimal literature on the clinical use of NMDA antagonists, it is difficult to provide guide- Tizanidine is a centrally acting α -adrenergic agonist lines. REFERENCES Tizanidine is indicated for the treatment of spasticity secondary to spinal cord injury and multiple sclerosis. Methotrimepraxine: A new phenothiazine derivative with analgesic properties. Chlorprothixene therapy for herpes carisoprodol, chlorphenesin carbamate, chlorzoxa- zoster neuralgia. Chlorprothixene in post-herpetic neuralgia and other severe chronic pain. Validity and sensi- Many of these are available in combination with cer- tivity of ratio scales of sensory and affective verbal pain tain other drugs. Comparison of the analgesic effect of Cyclobenzaprine is structurally similar to the tricyclic morphine, hydroxyzine and their combinations in patients antidepressants. Analgesic/calmative effects of acetaminophen and pheynyltoloxamine in treatment of simple nervous ten- NMDA RECEPTOR ANTAGONISTS sion accompanied by headache. Caffeine as an an influx of calcium, which initiates a cascade of adjuvant analgesic. Section V ACUTE PAIN MANAGEMENT in analgesic requirements between patients and even 17 INTRAVENOUS AND within patients. SUBCUTANEOUS PATIENT- Variability in patient-specific opioid requirements CONTROLLED ANALGESIA during PCA therapy results from differences in phar- macokinetics, pharmacodynamics, pain intensity, Anne M. Savarese, MD psychological makeup, anxiety, and previous painful experiences.

Myoglobin is toxic to kidneys and myoglobinuria should be treated with mannitol diuresis and alkalin- ization of the urine with bicarbonate 100 mg viagra soft for sale. It is important to monitor urine color during resuscitation to check for development of myoglobinuria buy discount viagra soft 100mg online. For patients who have survived the resuscitation phase with renal function intact, overwhelming infection and sepsis also pose a threat to the kidneys. In these cases every effort must be made to preserve renal perfusion and oxygen delivery. In the preoperative evaluation it is important to review laboratory values to check renal function. PHARMACOLOGICAL CONSIDERATIONS Physiological and metabolic changes resulting from large burn injuries and their medical treatment may dramatically alter patients’ responses to drugs. Responses are altered by pharmacokinetic as well as pharmacodynamic determinants. At the very least, consid- eration of altered response may require deviation from usual dosages in order to avoid toxicity or decreased efficacy. At the other extreme, potentially lethal ef- fects of succinylcholine contraindicate the use of this drug for a limited period following large burn injuries. The complex nature of pathophysiological changes, interpatient variation in nature and extent of burns, as well as the dynamic nature of these changes during resuscitation and recovery make it difficult to formulate precise dosage guidelines for burn patients. Effective drug therapy in burn patients requires careful monitoring of effects and titration of dosage to the desired response. Anesthesia 117 The two phases of cardiovascular response to thermal injury affect pharma- cokinetic parameters in different ways. During the resuscitation phase, loss of fluid from the vascular space causes decreased cardiac output and perfusion of tissues including kidney and liver where much drug elimination takes place. Decreased cardiac output will accelerate the rate of alveolar accumulation of inhalation agents and can result in exaggerated hypotension during induction of general anesthesia. Volume resuscitation during this phase dilutes plasma proteins and expands the extravascular space especially, but not exclusively, around the burn injury itself. These changes tend to increase sensitivity and prolong the action of many drugs during the first 1–2 days postinjury. From 2 to 3 days after burn injury, a hypermetabolic and hyperdynamic circulatory phase is established that has different effects on pharmacokinetic vari- ables and drug responses compared with the resuscitation phase. During this phase increased body temperature, oxygen consumption, and cardiac output are associated with increased perfusion of liver and kidney and increased activity of some drug-metabolizing enzymes. During this phase clearance of some drugs is increased to the point that increased dosages are required. This can affect drug response because many anesthetic drugs are highly protein-bound. For highly protein-bound drugs, drug action and elimination are often related to the unbound fraction of the drug available for receptor interaction, glomerular filtration, or enzymatic metabolism. There are two major drug-binding proteins in the plasma and they are affected in opposite ways by burn injury.

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