Many common surgeries and diseases are associated with an increased risk of chronic opioid use, including patients with kidney failure who may experience pain that is multifactorial in nature or related to concomitant comorbidities. [1][2][3] Inadequate pain control has been associated with prolonged hospital length of stay (LOS), increased readmission secondary to pain, and decreased quality of life. 1 One promising strategy for reducing opioid use in the operative setting is the use of multimodal analgesia extrapolated from an enhanced recovery after surgery pathway (ERAS). The ERAS pathways utilize multimodal analgesia and focus on a set of protocols implemented before, during, and after surgery to ensure optimal outcomes. The intended outcomes include reduction or elimination of opioid use postoperatively or at discharge. Compared with traditional management, multimodal analgesia can reduce opioid use, in the immediate and long-term post-surgical periods. 4 To date, there are minimal data published on minimizing and reducing opioid use postoperatively in this surgical transplant population.Existing literature has elucidated the negative effects of opioids in the transplant population. The use of pre-surgical opioid analgesics has been increasingly recognized as a predictor of postoperative complications and resource utilization in a variety of surgical populations, including general, orthopedic, and liver transplant surgeries. [5][6][7] Opioid use prior to kidney transplantation was strongly associated with inferior one-year post-transplant outcomes. High-level opioid

Introduction: Fracture of both bones forearm in adults occupy a large field of modern traumatology. Maintenance of radial bow, regaining length, good apposition and alignment without malrotation is essential to restore good range of motion of forearm. Aim: to compare functional and radiographic results of plate osteosynthesis to IM nailing in treatment of diaphyseal forearm fracture in adults. Method: a prospective study comprising of 30 patients. 15 patients treated with open reduction and internal fixation using 3.5 mm DCP and 15 patients by IM nailing using 316L SS Talwarkar square nailing by closed or mini open reduction. Result: mean age of patients was 36.4 years (range 20 to 58 years), most fractures were of type 22A3 as per AO/OTA classification. Average operative time was 83 minutes and 64 minutes in plating and nailing respectively. 2 cases of infection each in plating and nailing was seen which were superficial. Mean time of union in plating group was 12.8 weeks (range 10-18 weeks) with union achieved in all cases and DASH score of 14.7(range 4.1-33.3) with excellent functional results in 73.3% cases. In nailing group, 2 cases of non-union was seen (13.3%) with mean time of union 14.6 weeks (range 11-22 weeks) and DASH score of 18.5(range 5-45) with excellent functional results in 53.3% cases. Conclusion:We conclude that open reduction and internal fixation with dynamic compression plating is gold standard for treating diaphyseal forearm fracture in adults as it provides rigid fixation, restores forearm stability earlier and has negligible complications.

Introduction: Fractures of the proximal humerus constitutes 7% of all fractures and approximately onehalf of all humerus fractures. In the elderly population above 65 years of age, these are second most frequent upper extremity fracture and third most common non vertebral osteoporotic fractures. Management of proximal humerus fracture with various treatment modalities has always been a topic of debate and draws much controversy and confusion with it because of the complexity of these injuries with fracture displacements. Moreover, even good anatomical results achieved with operative fixation may lead to poor results unless supported by a meticulous postoperative rehabilitation. Aim: To assess and compare the functional outcome with different modalities of the fixations in proximal humerus fractures. Method: A prospective study comprising of 23 patients with proximal humerus fractures classified through Neer's classification. Modalities of treatment employed included (1) Closed reduction and Percutaneous K-wire fixation (2) Open reduction and Internal fixation with Locking Compression Plate (PHILOS) (3) Closed reduction and Internal fixation with Intramedullary Nail and (4) Shoulder Hemiarthroplasty. Functional outcome was evaluated using Constant Murley score and American Shoulder and Elbow Surgeons Shoulder Score (ASES) based on pain, function, strength and range of motion. Result: Higher incidence of these fracture was seen in (61%) females as compared to males. Most of the fractures (43%) occurred in the age group 50-60 years. Fall from a standing height was the most common mode of trauma in elderly patients while in younger patients, these fractures were mostly a result of RTA or sporting injuries. Two part and three part fractures were found to be commoner of all fractures constituting 39% and 34.8% respectively. Functional outcome evaluated using Constant Murley Score shown Excellent outcome in 13% cases, Good outcome in 34.8% cases and Fair outcome in 39.1% cases while in 13% patients, outcome was poor. The unsatisfactory results in our series was seen mostly in elderly patients who were reluctant or not compatible for rigorous rehabilitation program. Conclusion:Fractures of the proximal humerus have varied patterns and are complex injuries to manage. Reconstruction of the articular surface with restoration of the anatomy, achieving stable fixation, with minimal soft tissues damage and preservation of blood supply remains the key for attainment of optimal functional outcome.

Introduction: Distal humerus fracture in adults particularly complete articular (AO/OTA Type C) remain some of the most difficult injuries to manage. Complex anatomy of distal humerus combined with multifragmented fracture, sparse soft tissue cover with adjacent neurovascular structures poses great difficulty for treatment. Goal of treatment is to obtain a painless, stable and mobile elbow joint through a systematic approach. Aim: to study the functional outcome of surgical management of complete articular distal humerus fracture in adults. Method: a prospective study comprising of 20 patients treated surgically with open reduction and internal fixation using Orthogonal plating (dorsolateral and medial 3.5mm LCP) through trans olecranon approach. Result: Mean age of patients was 36.6 years (range 19 to 58 years) with male dominance, most fractures were of type 13C1 (AO/OTA). RTA accounts for most common mode of injury, majority of them being left sided. Mean operative time was 130 minutes. Complications included one case of superficial infection, 3 cases of ulnar neuropathy and non-union in 2 cases. Mean range of motion of elbow was 89 degree. Functional outcome assessed using Mayo Elbow Performance Score (MEPS) shown Excellent result in 12 cases, good to fair results in 6 and poor result in 2 cases. Conclusion: Anatomical restoration of joint surface and rigid internal fixation with bicolumnar orthogonal plating allowing early range of motion is the key for obtaining good functional results in complete articular distal humerus fractures. However, outcomes do deteriorate with increasing fracture complexity.