Diss. (sammanfattning) Uppsala : Uppsala universitet, 2005. / Härtill 5 uppsatser.

A artroscopia tem função diagnóstica e terapêutica na doença articular. Mesmo com as modalidades de imagem mais modernas, ainda é considerada como padrão ouro no diagnóstico de problemas articulares em equinos. Sabe-se que as características físico-químicas das diferentes soluções de infusão podem determinar alterações estruturais na superfície da cartilagem. Apesar da existência de estudos baseados na busca de um fluido ideal para irrigação durante a artroscopia, com principal foco nas características bioquímicas do líquido, poucos trabalhos testaram características físicas destes fluidos, como a temperatura. Na primeira etapa deste trabalho foram avaliadas 24 articulações de ovinos submetidas à irrigação articular com solução de Ringer com lactato condicionado a quatro diferentes temperaturas (5, 12, 25 e 38 ºC). Para avaliação de cada grupo foram coletadas biopsias comparativas de membrana sinovial e de cartilagem com osso subcondral da articulação femoropatelar visando análise histológica e por microscopia eletrônica de varredura, respectivamente, imediatamente antes do início da infusão do líquido e após uma hora de infusão. Apesar de alterações na ultraestrutura da superfície articular terem sido observadas após lavagem das articulações, nenhuma diferença estatística entre os grupos foi identificada. Na segunda etapa do experimento foram testadas as temperaturas 5, 25 e 38 °C do Ringer com lactato utilizado para irrigação articular durante procedimentos artroscópicos em 12 articulações radiocárpicas de seis equinos. As articulações foram divididas em três grupos de quatro, sendo avaliados, além da membrana sinovial e cartilagem, o líquido sinovial previamente ao início da infusão com fluido condicionado e 12, 24 e 48 horas após o término da irrigação, visando análise comparativa das concentrações de IL-1β, PGE2, TNF-α, condroitim sulfato (CS) e ácido hialurônico (AH). As alterações da superfície articular dos equinos decorrentes da irrigação também foram independentes da temperatura utilizada. Houve um aumento significativo das concentrações de PGE2 e IL-1β no líquido sinovial às 12 horas em todos os grupos, exceto para IL-1β no grupo de articulações irrigadas com fluido a 38 °C, que não apresentou alteração nas concentrações. A análise de TNF-α não revelou diferença significativa entre os grupos. As concentrações de CS aumentaram às 24 horas nos três grupos e foi estatisticamente maior no grupo irrigado a 38 °C. Não houve diferença significativa das concentrações de AH no líquido sinovial do grupo de articulações irrigadas a 25 °C, o que não ocorreu nos grupos 5 e 38 °C, havendo diminuição às 24 e 12 horas, respectivamente, retornando aos valores basais na coleta subsequente. As biopsias de membrana sinovial coletadas em ambas as etapas do experimento não demonstraram alteração estrutural ou migração celular que inferissem em resposta inflamatória ao insulto. As alterações da ultraestrutura da superfície da cartilagem estão mais relacionada ao fator mecânico da passagem do líquido que à temperatura de acondicionamento. Apesar de mais análises serem necessárias para definição da melhor temperatura a ser utilizada durante as artroscopias, a detecção de menores concentrações de IL-1β nas articulações de equinos irrigadas com Ringer com lactato a 38 °C sugerem de que essa seja a temperatura menos deletéria para o ambiente articular. / Arthroscopy has a diagnostic and a therapeutic function in joint disease. Even with modern imaging modalities, it is still considered the gold standard for diagnosing equine joint problems. It is known that the physicochemical characteristics of different infusion solutions could influence structural modifications on cartilage surface. A number of studies have described the search for the ideal fluid to be used for irrigation during arthroscopy, focusing on the biochemical characteristics of the various liquids. However, few works have taken temperature into consideration when studying the physical characteristics of these fluids. Therefore, in the first phase of this study four different temperatures of Ringer lactate used for articular irrigation were assessed into four groups of six ovine joints each (5, 12, 25 and 38 ºC). To evaluate each group, comparative synovial membrane and osteochondral samples were collected from the patellofemoral joints for histological analysis and Scanning Electron Microscopy, respectively, immediately before and 1 hour after starting fluid infusion. Ultrastructural changes of the joint surfaces after irrigation were observed, but no statistical differences between groups were identified. In the second phase of this study, lactated Ringers solution was assessed at three different temperatures: 5, 25 and 38°C, for irrigation of 12 radiocarpal joints of six horses during arthroscopy. Three groups of four joints were studied to evaluate synovial membrane, cartilage and synovial liquid immediately before and 12, 24 and 48 hours after joint irrigation. These samples were subjected to comparative analysis of IL-1&beta, PGE2, TNF-&alpha, condroitin sulfate (CS) and hyaluronic acid (HA) concentrations. Changes of equine joint surfaces were also independent of temperature. There was a significant increase in the PGE2 and IL-1β concentrations in the synovial liquid at 12 hours in all groups except for IL-1β on the joints irrigated with fluid at 38°C, which did not show concentrations changes. There was no statistical difference of TNF-&alpha between groups. CS concentrations had a significant increase at 24 hours in all groups, meanwhile in the 38 °C group this increased was statistically greater. There was no statistical difference for HA concentrations on synovial liquid of the irrigated joints at 25 °C. In the 5 and 38 °C groups there were synovial fluid HA decrease at 24 and 12 hours, respectively, returning to basal values at the subsequent collect. The synovial membrane biopsies collected in the both steps of this study did not show any structural alterations or cellular migration that might interfere in response to inflammatory insult. Ultrastructural changes in articular most superficial zone are more related to mechanic action of fluid lavage than irrigation solutions temperature. Although more tests needs to be done, the lowest concentrations of IL-1β in equine joints irrigated with Ringer lactate at 38 °C give some evidence that this is the less deleterious temperature to articular environment.

A artroscopia tem função diagnóstica e terapêutica na doença articular. Mesmo com as modalidades de imagem mais modernas, ainda é considerada como padrão ouro no diagnóstico de problemas articulares em equinos. Sabe-se que as características físico-químicas das diferentes soluções de infusão podem determinar alterações estruturais na superfície da cartilagem. Apesar da existência de estudos baseados na busca de um fluido ideal para irrigação durante a artroscopia, com principal foco nas características bioquímicas do líquido, poucos trabalhos testaram características físicas destes fluidos, como a temperatura. Na primeira etapa deste trabalho foram avaliadas 24 articulações de ovinos submetidas à irrigação articular com solução de Ringer com lactato condicionado a quatro diferentes temperaturas (5, 12, 25 e 38 ºC). Para avaliação de cada grupo foram coletadas biopsias comparativas de membrana sinovial e de cartilagem com osso subcondral da articulação femoropatelar visando análise histológica e por microscopia eletrônica de varredura, respectivamente, imediatamente antes do início da infusão do líquido e após uma hora de infusão. Apesar de alterações na ultraestrutura da superfície articular terem sido observadas após lavagem das articulações, nenhuma diferença estatística entre os grupos foi identificada. Na segunda etapa do experimento foram testadas as temperaturas 5, 25 e 38 °C do Ringer com lactato utilizado para irrigação articular durante procedimentos artroscópicos em 12 articulações radiocárpicas de seis equinos. As articulações foram divididas em três grupos de quatro, sendo avaliados, além da membrana sinovial e cartilagem, o líquido sinovial previamente ao início da infusão com fluido condicionado e 12, 24 e 48 horas após o término da irrigação, visando análise comparativa das concentrações de IL-1β, PGE2, TNF-α, condroitim sulfato (CS) e ácido hialurônico (AH). As alterações da superfície articular dos equinos decorrentes da irrigação também foram independentes da temperatura utilizada. Houve um aumento significativo das concentrações de PGE2 e IL-1β no líquido sinovial às 12 horas em todos os grupos, exceto para IL-1β no grupo de articulações irrigadas com fluido a 38 °C, que não apresentou alteração nas concentrações. A análise de TNF-α não revelou diferença significativa entre os grupos. As concentrações de CS aumentaram às 24 horas nos três grupos e foi estatisticamente maior no grupo irrigado a 38 °C. Não houve diferença significativa das concentrações de AH no líquido sinovial do grupo de articulações irrigadas a 25 °C, o que não ocorreu nos grupos 5 e 38 °C, havendo diminuição às 24 e 12 horas, respectivamente, retornando aos valores basais na coleta subsequente. As biopsias de membrana sinovial coletadas em ambas as etapas do experimento não demonstraram alteração estrutural ou migração celular que inferissem em resposta inflamatória ao insulto. As alterações da ultraestrutura da superfície da cartilagem estão mais relacionada ao fator mecânico da passagem do líquido que à temperatura de acondicionamento. Apesar de mais análises serem necessárias para definição da melhor temperatura a ser utilizada durante as artroscopias, a detecção de menores concentrações de IL-1β nas articulações de equinos irrigadas com Ringer com lactato a 38 °C sugerem de que essa seja a temperatura menos deletéria para o ambiente articular. / Arthroscopy has a diagnostic and a therapeutic function in joint disease. Even with modern imaging modalities, it is still considered the gold standard for diagnosing equine joint problems. It is known that the physicochemical characteristics of different infusion solutions could influence structural modifications on cartilage surface. A number of studies have described the search for the ideal fluid to be used for irrigation during arthroscopy, focusing on the biochemical characteristics of the various liquids. However, few works have taken temperature into consideration when studying the physical characteristics of these fluids. Therefore, in the first phase of this study four different temperatures of Ringer lactate used for articular irrigation were assessed into four groups of six ovine joints each (5, 12, 25 and 38 ºC). To evaluate each group, comparative synovial membrane and osteochondral samples were collected from the patellofemoral joints for histological analysis and Scanning Electron Microscopy, respectively, immediately before and 1 hour after starting fluid infusion. Ultrastructural changes of the joint surfaces after irrigation were observed, but no statistical differences between groups were identified. In the second phase of this study, lactated Ringers solution was assessed at three different temperatures: 5, 25 and 38°C, for irrigation of 12 radiocarpal joints of six horses during arthroscopy. Three groups of four joints were studied to evaluate synovial membrane, cartilage and synovial liquid immediately before and 12, 24 and 48 hours after joint irrigation. These samples were subjected to comparative analysis of IL-1&beta, PGE2, TNF-&alpha, condroitin sulfate (CS) and hyaluronic acid (HA) concentrations. Changes of equine joint surfaces were also independent of temperature. There was a significant increase in the PGE2 and IL-1β concentrations in the synovial liquid at 12 hours in all groups except for IL-1β on the joints irrigated with fluid at 38°C, which did not show concentrations changes. There was no statistical difference of TNF-&alpha between groups. CS concentrations had a significant increase at 24 hours in all groups, meanwhile in the 38 °C group this increased was statistically greater. There was no statistical difference for HA concentrations on synovial liquid of the irrigated joints at 25 °C. In the 5 and 38 °C groups there were synovial fluid HA decrease at 24 and 12 hours, respectively, returning to basal values at the subsequent collect. The synovial membrane biopsies collected in the both steps of this study did not show any structural alterations or cellular migration that might interfere in response to inflammatory insult. Ultrastructural changes in articular most superficial zone are more related to mechanic action of fluid lavage than irrigation solutions temperature. Although more tests needs to be done, the lowest concentrations of IL-1β in equine joints irrigated with Ringer lactate at 38 °C give some evidence that this is the less deleterious temperature to articular environment.

published_or_final_version / Dental Surgery / Master / Master of Dental Surgery

Osteoarthritis (OA) is a degenerative disease of the joint that leads to joint instability, degradation of the articular cartilage surface and eventually joint failure. Articular cartilage surfaces exhibit unique mechanical behaviors, bearing and distributing loads across joint surfaces, but have poor regenerative capacities. Human Mesenchymal Stem Cells (hMSCs) present a promising treatment to target OA, relying on their regenerative capacity and structural contributions to tissue repair, along with their immunomodulatory and anti-inflammatory properties. The multipotency of hMSCs allow these cells to differentiate towards osteogenic, chondrogenic and adipogenic lineages and directly incorporate into native tissue. hMSCs also possess the capacity to induce numerous paracrine-mediated processes including the recruitment of stem and progenitor cells, prevention of apoptosis, facilitation of beneficial remodeling and modulation of the immune response. Through encapsulating hMSCs, the effects of their paracrine action were studied directly, as the capsule presents a mechanical barrier for direct physical interaction and integration of these cells within the native tissue. The objective of this study was to utilize encapsulation of hMSCs to determine the paracrine effects of hMSCs on the progression of OA. OA was surgically induced in rats via the medial meniscus transection (MMT) surgery, which presents the phenotypical cartilage degradation associated with OA at 3 weeks. The efficacy of hMSC intervention was assessed using Lewis Rats with MMT (n=5 per group). Intra-articular injections of encapsulated hMSCs were given one day post-op and 3 weeks post-op for the 3-week and 6-week MMT studies, respectively. Animals were euthanized on the final day for both the immediate and delayed treatment studies. Micro-structural changes of the articular cartilage, osteophytes and subchondral bone of the medial tibial plateau were assessed using contrast enhanced microCT. We hypothesized that the intra-articular delivery of encapsulated hMSCs will have a positive effect, via paracrine-mediated action, on the onset and development of OA. The capsules also have the potential to improve retention and cell viability in the knee joint space. Each of these factors could contribute to enhanced therapeutic potential of the hMSC treatment. Utilizing NIR labeled sodium alginate capsules, a retention profile for the capsules yielded a tau value of 11.48 days, whereas previous studies have shown scaffold free hMSCs show complete clearance in 7 days. The 3-week MMT, run to analyze the effects of immediate treatment of encapsulated hMSCs on the onset of OA, showed a trend towards decreased cartilage thickness and a decreased surface roughness for the hMSC group in comparison to the Saline group, specifically. Additionally, the hMSC group showed a trend towards increased mineralized osteophyte volume for the hMSC group in comparison to the Saline group. Analysis of the subchondral bone yielded no differences between the hMSC and Saline groups for bone morphology. The 6 week MMT study was run to analyze the effects of a delayed treatment of encapsulated hMSCs on OA after the disease had developed. This study showed a similar result with the immediate treatment study for surface roughness, with the hMSC group showing a decrease in comparison to the Saline group. However, no differences were noted for cartilage thickness between the two respective groups. To further analyze the cartilage in the later stages of OA, exposed bone was quantified yielding a trend towards decreased exposed bone in the hMSC group in comparison to the Saline group. The mineralized osteophyte volume for the hMSC group, of the delayed treatment study, yielded a significantly higher value than all other groups. Additionally, the subchondral bone of the hMSC group trended towards a decreased porosity in comparison to the Saline group. This is one of the first studies to use sodium alginate encapsulation of hMSCs as an innovative scaffold means for intra-articular injections into the knee space. Encapsulated hMSCs permitted not only enhanced cellular retention in the knee space but showed a potential chondroprotective role of the paracrine signaling properties of hMSCs in the early stages of OA. These advantages of encapsulated hMSCs were countered by enhancements of secondary OA phenotypic changes, mainly increased mineralized osteophyte volume and a trend towards increased subchondral bone sclerosis in the later stages of OA. hMSCs have shown great potential as disease modifying drugs and through this study we have further explored the efficacy of these drugs for future treatments of OA. This study has high clinical relevance and with clinical practice running well ahead of current scientific evidence, it is imperative that these findings be considered not only in pre-clinical work but in current and future clinical trials. / 2018-07-11T00:00:00Z

Intra-articular fractures (IAFs) often lead to poor outcomes, despite surgeons’ best efforts at reconstructing the fractured articular surface. The objective of articular fracture reduction is to improve joint congruity thereby lower articular contact pressure and minimize the risk of post-traumatic osteoarthritis (PTOA). Surgical fracture reductions performed using less invasive approaches (i.e., percutaneously) rely heavily upon C-arm fluoroscopy to judge articular surface congruity. Based on varied outcomes, it appears that the use of 2D imaging alone for this purpose may prove inadequate. Despite this, there has been little investigation into novel metrics for assessment of reduction quality. This work first explores seven methods for assessment of reduction quality (3 2D, 3 3D, and one biomechanical). The results indicate that metrics which take 3D measurement or joint biomechanics into account when characterizing reduction quality are more strongly correlated with PTOA development. A computer assisted surgery system, which provides up-to-date 3D fracture geometry and contact stress distributions intra-operatively, was developed. Its utility was explored in a series of ten cadaveric tibial plafond fracture reductions, where contact stresses and contact areas were compared in surgeries with vs. without biomechanical guidance. The use of biomechanical guidance caused an increase in surgical time and fluoroscopy usage (39% and 17%, respectively). However, it facilitated decreases in the mean and maximum contact stress by 0.7 and 1.5 MPa, respectively. Contact areas engaged at known deleterious levels (contact stress > 4.5 MPa) were also 44% lower in cases which used guidance. The findings of this work suggest that enhanced visualization of a fracture intra-operatively may facilitate improved long-term outcomes. Further development and study of this system is warranted.

Highly comminuted intra-articular fractures are complex and difficult injuries to treat. Once emergent care is rendered, the definitive treatment objective is to restore the original anatomy while minimizing surgically induced trauma. Operations that use limited or percutaneous approaches help preserve tissue vitality, but reduced visibility makes reconstruction more difficult. A pre-operative plan of how comminuted fragments would best be re-positioned to restore anatomy helps in executing a successful reduction. The objective of this work was to create new virtual fracture reconstruction technologies that would deliver that information for a clinical series of severe intra-articular fractures. As a step toward clinical application, algorithmic development benefits from the availability of more precise and controlled data. Therefore, this work first developed 3D puzzle solving methods in a surrogate platform not confounded by various in vivo complexities. Typical tibial plafond fracture fragmentation/dispersal patterns were generated with five identical replicas of human distal tibia anatomy that were machined from blocks of high-density polyetherurethane foam (bone fragmentation surrogate). Replicas were fractured using an instrumented drop tower and pre- and post-fracture geometries were obtained using laser scans and CT. A semi-automatic virtual reconstruction computer program aligned fragment native surfaces to a pre-fracture template. After effective reconstruction algorithms were created for the surrogate tibias, the next aim was to develop new algorithms that would accommodate confounding biologic factors and puzzle solve clinical fracture cases. First, a novel image analysis technique was developed to segment bone geometries from pre- and post-surgical reduction CT scans using a modified 3D watershed segmentation algorithm. Next, 3D puzzle solving algorithms were advanced to obtain fracture reconstructions in a series of highly comminuted tibial plafond fracture cases. Each tibia was methodically reconstructed by matching fragment native (periosteal and articular) surfaces to an intact template that was created from a mirror image of the healthy contralateral limb. Virtual reconstructions obtained for ten tibial plafond fracture cases had average alignment errors of 0.39±0.5 mm. These novel 3D puzzle solving methods are a significant advancement toward improving treatment by providing a powerful new tool for planning the surgical reconstruction of comminuted articular fractures.

Osteoarthritis (OA) is the most common type of arthritis, a disease in which inflammation and stiffness of the joints occur. This debilitating disease of the joints currently reigns as the most prevalent among the world's populations. Of particular interest to our group is the study of the biomechanical factors relating to knee OA. Studies have shown that knee OA is related to multiple biomechanical factors, all of which are complexly interrelated. These factors have been seen to produce varied effects on the structures of the knee. This work examines validation of a computational model implementing discrete element analysis, and discusses the potential for large-scale, subject-specific modeling of the knee. In particular, contact stress can be estimated using this technique, and these estimates can potentially be related to OA onset in subjects.

Artroskopinė priekinio kryžminio raiščio rekonstrukcija – viena iš dažniausiai atliekamų ortopedinių operacijų. Adekvati skausmo kontrolė yra svarbi siekiant efektyvios ankstyvos reabilitacijos ir gerų funkcinių rezultatų, sutrumpinant gydymo ligoninėje trukmę. Atlikome randomizuotą perspektyvųjį dvigubai aklą placebu kontroliuojamą tyrimą panaudodami intrasąnarinius vaistus (morfiną ir neostigminą), derindami su vienkartine šlauninio nervo blokada. Taip pat tyrėme tęstinį skausmo malšinimą šlaunies perineuriniu kateteriu, taikydami du skirtingus paciento kontroliuojamos analgezijos režimus. Taikėme mažesnę vietinio anestetiko koncentraciją, siekdami selektyvesnės sensorinės blokados, mažesnės paros dozės, mažiau toksinių reakcijų. Tikrinome, ar tęstinis skausmo malšinimas yra veiksmingesnis nei vienkartinė nervo blokada su intrasąnarinėmis analgetikų injekcijomis. Intrasąnarinis morfinas turėjo panašų analgezinį poveikį kaip ir neostigminas paciento krūvio metu per visą tyrimo laiką (48 val.); tačiau neostigminas buvo patikimai efektyvesnis už placebą antrą pooperacinę dieną. Skausmo kontrolė ramybėje ir krūvio metu bei pacientų pasitenkinimas per visą tyrimą buvo geresni perineurinio skausmo malšinimo grupėse negu intrasąnarinėse. Intrasąnarinių grupių pacientų analgezijos efektyvumui priartėjus prie kateterinių grupių, nustatydavome didesnį papildomų analgetikų suvartojimą pirmosiose. Skausmo malšinimas 0,1% bupivakaino infuzija šlaunies perineuriniu kateteriu, taikant... [toliau žr. visą tekstą] / Choice of optimal postoperative analgesia technique after anterior crutiate ligament repair remains challenging. Aiming to evaluate and compare the efficacy of intra-articular injection of morphine and neostigmine our prospective randomized clinical study compared pain intensity, consumption of adjunct analgesics and patient satisfaction during 48 postoperative hours in patients who, in addition to spinal block, received a single-shot femoral nerve block followed by the end-of-surgery intra-articular injection of morphine, neostigmine or placebo. Additionally, the former two were compared with continuous femoral nerve block with postoperative patient controlled analgesia infusion pump containing 0.1 % bupivacaine preset in 2 different regimens: with or without basal infusion. Our results show that there was only a single difference among intra-articular groups found on the 2nd postoperative day: a significantly better pain control at motion in neostigmine group than in the placebo group. There was no additive analgesic effect of i/a morphine. Also, we observed a significantly better pain control and patient satisfaction in continuous femoral perineural block PCA groups during the whole trial. There was a significant prevalence of the PCA analgesia regimen which implies the preset basal rate of 0.1% bupivacaine: a 5 ml bolus with a lockout period 30 min and basal infusion 5 ml/h.

Choice of optimal postoperative analgesia technique after anterior crutiate ligament repair remains challenging. Aiming to evaluate and compare the efficacy of intra-articular injection of morphine and neostigmine our prospective randomized clinical study compared pain intensity, consumption of adjunct analgesics and patient satisfaction during 48 postoperative hours in patients who, in addition to spinal block, received a single-shot femoral nerve block followed by the end-of-surgery intra-articular injection of morphine, neostigmine or placebo. Additionally, the former two were compared with continuous femoral nerve block with postoperative patient controlled analgesia infusion pump containing 0.1 % bupivacaine preset in 2 different regimens: with or without basal infusion. Our results show that there was only a single difference among intra-articular groups found on the 2nd postoperative day: a significantly better pain control at motion in neostigmine group than in the placebo group. There was no additive analgesic effect of i/a morphine. Also, we observed a significantly better pain control and patient satisfaction in continuous femoral perineural block PCA groups during the whole trial. There was a significant prevalence of the PCA analgesia regimen which implies the preset basal rate of 0.1% bupivacaine: a 5 ml bolus with a lockout period 30 min and basal infusion 5 ml/h. / Artroskopinė priekinio kryžminio raiščio rekonstrukcija – viena iš dažniausiai atliekamų ortopedinių operacijų. Adekvati skausmo kontrolė yra svarbi siekiant efektyvios ankstyvos reabilitacijos ir gerų funkcinių rezultatų, sutrumpinant gydymo ligoninėje trukmę. Atlikome randomizuotą perspektyvųjį dvigubai aklą placebu kontroliuojamą tyrimą panaudodami intrasąnarinius vaistus (morfiną ir neostigminą), derindami su vienkartine šlauninio nervo blokada. Taip pat tyrėme tęstinį skausmo malšinimą šlaunies perineuriniu kateteriu, taikydami du skirtingus paciento kontroliuojamos analgezijos režimus. Taikėme mažesnę vietinio anestetiko koncentraciją, siekdami selektyvesnės sensorinės blokados, mažesnės paros dozės, mažiau toksinių reakcijų. Tikrinome, ar tęstinis skausmo malšinimas yra veiksmingesnis nei vienkartinė nervo blokada su intrasąnarinėmis analgetikų injekcijomis. Intrasąnarinis morfinas turėjo panašų analgezinį poveikį kaip ir neostigminas paciento krūvio metu per visą tyrimo laiką (48 val.); tačiau neostigminas buvo patikimai efektyvesnis už placebą antrą pooperacinę dieną. Skausmo kontrolė ramybėje ir krūvio metu bei pacientų pasitenkinimas per visą tyrimą buvo geresni perineurinio skausmo malšinimo grupėse negu intrasąnarinėse. Intrasąnarinių grupių pacientų analgezijos efektyvumui priartėjus prie kateterinių grupių, nustatydavome didesnį papildomų analgetikų suvartojimą pirmosiose. Skausmo malšinimas 0,1% bupivakaino infuzija šlaunies perineuriniu kateteriu, taikant... [toliau žr. visą tekstą]