Optimizing perioperative analgesia for patients undergoing operative fixation of hip fractures

This PhD thesis describes work carried out on investigation of various interventions with the aim to optimise the anaesthetic management of patients scheduled to undergo operative fixation of hip fractures. We analysed the perioperative effects of continuous femoral nerve block, single preoperative dose of i.v. dexamethasone, the intention to deposit local anaesthetic in different locations around the femoral nerve during ultrasound guided femoral nerve block, continuous spinal anaesthesia and peri-surgical site infiltration with local anaesthetic after surgical fixation of hip fractures. Continuous femoral nerve block provided more effective preoperative analgesia six hours after the insertion of the perineural catheter compared to a standard opiate-based regimen in patients undergoing operative fixation of fractured hip. A single low dose of preoperative dexamethasone in the intervention group decreased pain scores by 75% six hours after the surgery. Both interventions had no major effect on the functional recovery in the first year after the surgical fixation of fractured hip. The results of the ultrasound guided femoral nerve block trial showed no clinical advantage of intending to deposit local anaesthetic circumferentially during performing femoral nerve block. Using the Dixon and Massey’s “up- and-down” method, we demonstrated that intrathecal 0.26 ml of 0.5% bupivacaine provided adequate surgical anaesthesia within 15 minutes in 50% of patients undergoing operative fixation of hip fracture. Finally, we demonstrated that local anaesthetic infiltration had no effect on pain scores 12 hours after the surgical fixation of fractured neck of femur. In addition to this original body of work, a review article was published on femoral nerve block highlighting the use of ultrasound guidance. In conclusion, the results of this thesis offer an insight into interventions aimed at optimising perioperative analgesia in patients scheduled to undergo operative fixation of hip fractures.

Charge compensation and Ce3+ formation in trivalent doping of the CeO2(110) surface: The key role of dopant ionic radius

In this paper, we use density functional theory corrected for on-site Coulomb interactions (DFT + U) and hybrid DFT (HSE06 functional) to study the defects formed when the ceria (110) surface is doped with a series of trivalent dopants, namely, Al3+, Sc3+, Y3+, and In 3+. Using the hybrid DFT HSE06 exchange-correlation functional as a benchmark, we show that doping the (110) surface with a single trivalent ion leads to formation of a localized MCe / + O O • (M = the 3+ dopant), O- hole state, confirming the description found with DFT + U. We use DFT + U to investigate the energetics of dopant compensation through formation of the 2MCe ′ +VO ̈ defect, that is, compensation of two dopants with an oxygen vacancy. In conjunction with earlier work on La-doped CeO2, we find that the stability of the compensating anion vacancy depends on the dopant ionic radius. For Al3+, which has the smallest ionic radius, and Sc3+ and In3+, with intermediate ionic radii, formation of a compensating oxygen vacancy is stable. On the other hand, the Y3+ dopant, with an ionic radius close to that of Ce4+, shows a positive anion vacancy formation energy, as does La3+, which is larger than Ce4+ (J. Phys.: Condens. Matter 2010, 20, 135004). When considering the resulting electronic structure, in Al3+ doping, oxygen hole compensation is found. However, Sc 3+, In3+, and Y3+ show the formation of a reduced Ce3+ cation and an uncompensated oxygen hole, similar to La3+. These results suggest that the ionic radius of trivalent dopants strongly influences the final defect formed when doping ceria with 3+ cations. In light of these findings, experimental investigations of these systems will be welcome.

Role of the fibula in the stability of diaphyseal tibial fractures fixed by intramedullary nailing

Background: For tibial fractures, the decision to fix a concomitant fibular fracture is undertaken on a case-by-case basis. To aid in this clinical decision-making process, we investigated whether loss of integrity of the fibula significantly destabilises midshaft tibial fractures, whether fixation of the fibula restores stability to the tibia, and whether removal of the fibula and interosseous membrane for expediency in biomechanical testing significantly influences tibial interfragmentary mechanics. Methods: Tibia/fibula pairs were harvested from six cadaveric donors with the interosseous membrane intact. A tibial osteotomy fracture was fixed by reamed intramedullary (IM) nailing. Axial, torsion, bending, and shear tests were completed for four models of fibular involvement: intact fibula, osteotomy fracture, fibular plating, and resected fibula and interosseous membrane. Findings: Overall construct stiffness decreased slightly with fibular osteotomy compared to intact bone, but this change was not statistically significant. Under low loads, the influence of the fibula on construct stability was only statistically significant in torsion (large effect size). Fibular plating stiffened the construct slightly, but this change was not statistically significant compared to the fibular osteotomy case. Complete resection of the fibula and interosseous membrane significantly decreased construct torsional stiffness only (large effect size). Interpretation: These results suggest that fixation of the fibula may not contribute significantly to the stability of diaphyseal tibial fractures and should not be undertaken unless otherwise clinically indicated. For testing purposes, load-sharing through the interosseous membrane contributes significantly to overall construct mechanics, especially in torsion, and we recommend preservation of these structures when possible.