Average Visual Analogue Score Research Articles

Short-term Outcome Analysis of Proximal Fibular Osteotomy in Management of Osteoarthritis Knee

ABSTRACT Aim Proximal fibular osteotomy (PFO) for osteoarthritis (OA) knee is an emerging concept with good early results. This short-term study aimed to analyze the usefulness of PFO in Indian patients with OA knee with regard to pain relief and correction of deformity. Materials and methods This study involves a surgical technique where 2 cm of proximal fibular bone is resected, and patient is permitted full-weight-bearing walking as early as possible. Subjective and objective outcome analyses done using Lysholm knee scoring sheet and radiographs, respectively. Minimum follow-up time was 6 months. Results We had a of total of 20 knees in 18 patients, with average age of 56.1 years. The average visual analog score reduced by 6.8 points, and the average Lysholm knee score improved by an average of 34 points at the end of follow-up. The mean alpha angle correction achieved was 3.738°. The calculation of Pearson's correlation coefficient between the amount of correction of alpha angle and reduction of visual analog scale during the immediate postoperative period was −0.186. Among the 20 knees, we had four cases of weakness of extensor hallucis longus. Conclusion Through our short-term prospective cohort study, we conclude that PFO helps in improvement of pain and function, in patients suffering from medial compartment OA knee. The effectiveness of proximal tibiofibular joint mechanism in immediate pain relief is evident in our study by subjective and objective means. A proper selection of case with regard to severity and duration of disease and patellofemoral involvement is vital in getting good results. Clinical significance Proximal fibular osteotomy is an emerging concept in the management of OA of knee and gives the patient, more years, with native knee to walk. How to cite this article Gopi T, Thirunarayanan V, Manimaran KP, et al. Short-term Outcome Analysis of Proximal Fibular Osteotomy in Management of Osteoarthritis Knee. J Orth Joint Surg 2019;1(1):5–10.

Sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial.

Background and Aims:Sevoflurane is an excellent but expensive anesthetic agent for laparoscopic cholecystectomy. To decrease sevoflurane consumption during surgery adjuvants like dexmedetomidine may be used. Dexmedetomidine is a recently introduced drug which alleviates the stress response of surgery, produces sedation and analgesia. We aimed to evaluate sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy under entropy-guided general anesthesia (GA).Material and Methods:In this prospective randomized control study, 100 American Society of Anesthesiologists physical status I–II adult surgical patients scheduled to undergo laparoscopic cholecystectomy were enrolled. Patients were randomly divided into two groups (n = 50). In dexmedetomidine group, patients received intravenous (IV) dexmedetomidine 0.5 μg/kg over 10 min before induction followed by 0.5 μg/kg/h infusion while in control group, patients received the same volume of normal saline.Results:Sevoflurane consumption was 41% lower in dexmedetomidine group as compared to control group (7.1 [1.6] vs. 12.1 [1.9] ml, P <0.001). A 40% reduction was observed in induction dose of propofol (83.0 [19.1] vs. 127.6 [24.8] mg, P <0.001). Mean Riker sedation-agitation score, visual analog score for pain and Aldrete's score were significantly lower in dexmedetomidine group as compared to control group. None of the patients experienced any significant side effects.Conclusion:A 41% reduction in sevoflurane consumption was observed in patients receiving IV dexmedetomidine as an adjuvant in patients undergoing laparoscopic cholecystectomy under GA.

Single-stage anterior debridement and reconstruction with tantalum mesh cage for complicated infectious spondylitis.

AIMTo evaluate the clinical and radiographic results of patients with complicated infectious spondylitis treated with single-stage anterior debridement and reconstruction using tantalum mesh cage (TaMC) followed by immediate instrumentation.METHODSSingle-stage radical debridement and subsequent reconstruction with TaMC instead of autograft or allograft were performed to treat 20 patients with spinal deformity or instability due to complicated infectious spondylitis. Clinical outcomes were assessed by careful physical examination and regular serological tests to determine the infection control. In addition, the visual analog score (VAS), neurologic status, length of vertebral body reconstruction, and the correction of sagittal Cobb angle on radiography were recorded and compared before and after surgery. The conditions of the patients were evaluated based on the modified Brodsky’s criteria.RESULTSThe average VAS score significantly decreased after the surgery (from 7.4 ± 0.8 to 3.3 ± 0.8, P < 0.001). The average Cobb angle correction was 14.9 degrees. The neurologic status was significantly improved after the surgery (P = 0.003). One patient experienced refractory infection and underwent additional debridement. Eighteen patients achieved good outcome based on the modified Brodsky’s criteria and significant improvement after the surgery (P < 0.001). No implant breakage or TaMC dislodgement was found during at least 24 mo of follow-up.CONCLUSIONSingle-stage anterior debridement and reconstruction with TaMC followed by immediate instrumentation could be an alternative method to manage the patients with spinal deformity or instability due to complicated infectious spondylitis.

The role of minimally invasive spine surgery in the management of pyogenic spinal discitis.

Background:Diagnostic yields for spondylodiscitis from CT guided biopsy is low. In the recent years, minimally invasive surgery (MIS) has shown to have a low morbidity and faster recovery. For spinal infections, MIS surgery may offer an opportunity for early pain control while obtaining a higher diagnostic yield than CT-guided biopsies. The aim of this study was to review our patients who underwent MIS surgery for spinal infection and report outcomes.Methods:A retrospective review of seven patients who underwent MIS decompression and/or discectomy in the setting of discitis, osteomyelitis, spondylodiscitis, and/or an epidural abscess was identified. Patient data including symptoms, visual analog score (VAS), surgical approach, antibiotic regimen, and postoperative outcomes were obtained.Results:Of the 7 patients, 5 patients had lumbar infections and two had thoracic infections. All seven patients improved in VAS immediately after surgery and at discharge. The average VAS improved by 4.4 ± 1.9 points. An organism was obtained in 6 of the 7 (85%) patients by the operative cultures. All patients made an excellent clinical recovery without the need for further spine surgery. All patients who received postoperative imaging on follow-up showed complete resolution or dramatically improved magnetic resonance imaging changes. The follow-up ranged from 2 to 9 months.Conclusions:MIS surgery provides an opportunity for early pain relief in patients with discitis, osteomyelitis, spondylodiscitis, and/or epidural abscess by directly addressing the primary cause of pain. MIS surgery for discitis provides a higher diagnostic yield to direct antibiotic treatment. MIS surgery results in good long-term recovery.

Feasibility of biological acetabular component with high placement technique in hip revision arthroplasty

Objective To investigate the feasibility of biological acetabular component with high placement technique in hip revision arthroplasty. Methods From March 2006 to March 2015, 34 patients (35 hips) underwent hip revision arthroplasty with biological acetabular components with high placement technique. There were 15 males (15 hips) and 19 females (20 hips) with an average of 55 years (range, 26-74 years). There were 22 hips caused by aseptic loosening and 13 hips by infection. The acetabular bone defects included Paprosky IIA in 3 cases, IIB in 4, IIC in 2, IIIA in 17, and IIIB in 9. Modular tapered stems with distal fixation were performed in most femoral sides. The height of hip center was greater than 2.5 cm for all the patients, which were divided into two groups according to the degree of placement: 2.5-3.5 cm for the high placement group, greater than 3.5 cm for the high hip center group. Harris hip score, pain visual analogue score (VAS), leg length difference, gait characteristics were compared between two groups postoperatively and at the final follow-up respectively. The height of hip center and the horizontal distance between hip center and teardrop were measured in the hip X-ray. Radiolucent lines and migrations were also recorded. Results The average operation time and blood loss was 108 min (100-220 min) and 525 ml (300-1 200 ml) in two groups respectively. All the patients were followed up for average 49.2 months (range, 12-116 months). At the final follow-up, the average Harris hip score improved from 36.52±17.17 points preoperatively to 83.46±7.63 (t=18.99, P=0.001). The average VAS score decreased from 8.06±1.24 points preoperatively to 1.91±1.62 postoperatively (t=18.57, P=0.001). The height of hip center was 1.47±0.33 cm preoperatively and 3.85±1.13 cm postoperatively (t=12.15, P=0.001). The horizontal distance was 3.33±0.53 cm pre-operatively and 3.23±0.63 cm post-operatively (t=0.98, P=0.640). At the final follow-up, Trendelenburg sign improved from 25/10 (positive/negative, hips) preoperatively to 7/28 (χ2=18.65, P=0.001). There was 1 case of severe limp, moderate in 1, mild in 8 and other cases had no limp. The leg length discrepancy decreased from 1.84±1.92 cm preoperatively to 0.71±1.57 postoperatively (t=4.24, P=0.001). There were 6 cases of Paprosky IIIb with the use of ultra small cup and extremely high placement. The average Harris hip score improved from 26.65±13.46 points preoperatively to 79.83±10.55 (t=12.33, P=0.001). The average VAS score decreased from 8.50 ± 1.38 points preoperatively to 2.83 ± 2.64 postoperatively (t=4.61, P=0.006). One case had acetabular loosening at 4 years later postoperatively and re-revision surgery was performed. Other patients had no infection, dislocation, periprosthetic fracture or any other complications at the final follow-up. Conclusion Highly placement of biological acetabular component with a distal tapered modular stem can get enough contact with the host bone and achieve optimal clinical outcomes, regardless of the degree of high placement. Particularly, using ultra small cup in extremely high placement shows good effectiveness in simplified operation, and it can be used in many complicated or even impossible acetabular reconstruction. Key words: Arthroplasty, replacement, hip; Reoperation; Acetabulum; Osteolysis; Prosthesis-related infections

Clinical and pathological results of denosumab treatment for giant cell tumors of bone: Prospective study of 14 cases

ObjectiveGiant cell tumor of bone (GCT) is a primary, osteolytic, benign tumor of the bone. Surgery is the commonly used treatment; however, recurrence remains a problem. Receptor activator of nuclear factor kappa B (RANKL) is responsible for the formation of osteoclastic cells. Discovery of RANKL and its human monoclonal antibody, denosumab, led to use of denosumab for treatment of GCT. The aim of this study was to evaluate clinical and pathological results of treatment of GCT with denosumab and to assess adverse effect profile and recurrence rate. MethodsThirteen patients with 14 lesions were enrolled in the study. Mean age was 38.3 years. Patients were given subcutaneous injections of denosumab (120 mg) every 4 weeks (with additional doses on days 0, 8 and 15 in cycle 1 only) and were radiologically evaluated for tumor response. Pain and functional status were measured using Visual Analog Score (VAS) and Musculoskeletal Tumor Society Score (MSTS). Adverse effects were analyzed after each cycle. ResultsParticipants were 5 men and 8 women. Mean follow-up was 17 months. One lesion was Campanacci grade I, 8 were grade II, and 5 were grade III. Eight lesions were recurrent, and remaining were primary lesions. After average of 9 cycles (range: 4–17 cycles), all tumors underwent radiological regression. Ten lesions were removed surgically. More than 90% of giant cells were found to have regressed in all pathological specimens. On last follow-up, average VAS was 1 and MSTS was 87%. Fatigue and joint and muscle pain after injections was reported by 46% of patients, and mild hypocalcaemia was seen in 1 patient. ConclusionDenosumab has been shown to be a successful drug in treatment of GCT. Denosumab can be used as neoadjuvant for all recurrent lesions, grade II lesions with high surgical risk, grade III lesions, and metastatic cases of GCT. Level of evidenceLevel IV, Therapeutic study

Hernioplastias inguinales por vía laparoscópica. Experiencia inicial en 324 casos

IntroductionInguinal hernias are the most frequent pathologies a surgeon must know how to treat. Lately, their management with techniques using surgical mesh has become increasingly relevant, especially when repaired is done via laparoscopy. The purpose of this study is to show our initial experience in the laparoscopic treatment of inguinal hernias. Material and methodsA prospective descriptive study was carried out with all the patients submitted to laparoscopic inguinal repair at Gestion Salud Clinic in Cartagena, between June 2010 and May 2014. Special interest was drawn upon the impact of learning curve on the ocurrence of complication and the relationship between the number of tackers used with level of pain, analgesia requirement and time to return to habitual activities. ResultsA total of 412 inguinal repairs were performed in 324 patients. The average visual analog score (VAS) score at the seventh postoperative day was 5.8 (2-9) and 2 (0-8) at the thirtieth. The most painful postoperative score with more analgesic requirement and latest return to habitual activities was associated with the number of spiral staples used, the occurrence of complications, bigger body mass index, history of hernia recurrence, male sex and the younger the patient was. Hernia recurrence percentage of this series was 1.5%, with an average follow up of 26 months (14-61). ConclusionsLaparoscopic inguinal repair has a short learning curve in surgeons accustomed to laparoscopic techniques, it offers low index of complications and recurrence that never disappears, even above 100 cases. The possibility of visceral damage is always present, becoming more frequent in TAPP approach. In our experience, postoperative pain, analgesia requirement and the return to normal activities were related to fixation intensity (number of staples used).

Posterior Transpedicular Approach for Circumferential Decompression and Anterior Reconstruction Using Trabecular Metal Mesh Cage in Patients with Metastatic Spinal Tumor

Introduction The goal of surgical management for metastatic spinal tumors is to remove the tumor mass, restore the spinal stability and alignment, and provided better quality of life. Posterior transpedicular approach for circumferential decompression and reconstruction was proposed in concern of the morbidity related to anterior approach. We used this unique technique with trabecular metal (TM) mesh cage for anterior reconstruction to treat the patients with metastatic spinal tumor. Our purpose is to evaluate the feasibility and efficacy of this method as an alternative procedure for managing metastatic spinal tumors. Methods From January 2009 to December 2012, we performed single stage circumferential debridement and reconstruction with TM mesh cage through single posterior approach to treat 20 patients with metastatic spinal tumors. The visual analog score (VAS), neurologic status, vertebral body reconstruction, operation time, blood loss, and complications were recorded. The patient's conditions were evaluated on the basis of modified Brodsky's criteria which categorized them as excellent, good, fair, or poor. Results The average VAS score was 8.2 (range, 7 to 9) before surgery, which was significant decreased to 3.2 (range, 2 to 4) after surgery ( p &lt; 0.001). The average cobb's angle correction was 12 degree (range, 3 to 29). The neurologic status which classified by Frankel's scale was significant improved after surgery ( p &lt; 0.001). No one experienced severe complication such as deep infection or neurologic deterioration. Three patients experienced long-term paresthesia around nerve roots territory. Eighteen patients could achieve good or excellent outcome based on modified Brodsky's criteria and the improvement showed significant difference after surgery ( p &lt; 0.001). The blood loss and operative time in the last 10 cases was significantly decreased while comparing to the initial 10 cases ( p = 0.007 for blood loss and p = 0.005 for operative time). No significant difference in clinical outcome which classified by Macnab criteria between the initial and last 10 patients ( p = 0.654). Conclusions In our case series, good functional outcome and low complication rate could be achieved by single-stage posterior transpedicular approach. It could be an alternative method to manage the patients with metastatic spinal tumors.

Treatment of transforaminal wedge osteotomy for correction of the thoracolumbar kyphosis

Objective To evaluate the operation methods and effects of transforaminal wedge osteotomy (TWO) combined with intervertebral grafting bone for correcting the rigid thoracolumbar kyphosis. Methods From January 2003 to June 2013, treatment of 52 cases of the rigid thoracolumbar kyphosis by TWO combined with intervertebral bone graft were studied (including 33 males and 19 females, and the age range was from 15 to 72 with average age of 42.3 years old). In these 52 cases, there were 17 cases of ankylosing spondylitis, 25 cases of obsolete thoracolumbarvertebral fractures, 7 cases of chronic thoracolumbar tuberculosis and 3 cases of congenital vertebral malformations. 52 cases presented as lumbar kyphosis, low back pain aggravated, with an average VAS score of 8.6; 24 cases were accompanied with different extent of neurological dysfunction which obviously influenced daily life or work. Osteotomy was located at thoracolumbar intervertebral disc. Pedicle screws internal fixation system combined with intervertebral grafting bone was used to compress the vertebra and fuse after TWO for correction. Preoperative and postoperative low back pain was evaluated by visual analog score (VAS), Frankel score and Oswestry disability index(ODI) in patients with neurological dysfunction. The above indexes were compared with the PSO osteotomy group. Results Preoperative mean kyphosis Cobb angle was 65.6°(31°-137°). The average post-operative kyphosis Cobb angle was 19.2° (8°-35°), and the average correction rate was 68.4%. The mean operation time was 3.8 h (2.2-5.3 h), and the mean intraoperative blood loss was 1220 ml (500-2 900 ml). Preoperative VAS score was 8.6±1.2 while the last follow-up was 1.8±0.5; preoperative Oswestry dysfunction index was 75.6±8.2 while the last follow-up was 18.4±8.1. The results were statistically significant. The spinal function was 4 cases of Frankel C and 20 cases of Frankel D before operation, all of which dropped to E level after operation. 52 patients were followed up with the average time of 41 months (from 6 to 60 months). The bony fusion rate was 94.23% at 6 months after operation. All of the patients were fused in 3 years after operation. The average loss of kyphosis Cobb angle was 5.5°(4°-12°). Compared with PSO, the average operation time, the amount of bleeding and the improvement of neurological function after surgery all had some advantages. Conclusion Transforaminal wedge osteotomy has many advantages, such as less bleeding wounds, less nerve interference and limited multi-segmental osteotomy, with little trauma and high bony fusion rate. Key words: Thoracic vertebrae; Lumbar vertebrae; Kyphosis; Osteotomy; orthopedic surgery; Spinal fusion

Evaluation of therapeutic effectiveness and safety of botulinum toxin type A in the treatment of idiopathic trigeminal neuralgia in patients older than 70 years

To evaluate therapeutic effectiveness and safety of botulinum toxin type A in the treatment of idiopathic trigeminal neuralgia in patients older than 70 years. The total 64 patents were involved from neurology clinic and inpatient department from Aug 2008 to Sep 2013. They were divided into two groups according to the age (older than 70 years versus younger than 60 years. The therapeutic dose, safety, effectiveness were compared between two groups. Visual analog scores were employed to measure the degree of pain. The mean dosage was (88 ± 30) U in the group aged above 70 years old, and (72 ± 33) U in the group aged below 60 years old respectively. There was no significant difference of dosage between the two groups. The average visual analog score of all patients was (7.7 ± 2.2) before the treatment and decreased to (4.4 ± 2.9) one month after the treatment. To be precise, the average visual analog score of the group aged above 70 years old was (8.2 ± 1.9) before and (4.5 ± 3.2) after the treatment, and the visual analog score of the group aged below 60 years old was (7.2 ± 2.4) before and (4.4 ± 2.5) after the treatment. The effect of botulinum toxin type A in the treatment of idiopathic trigeminal neuralgia was considered statistically significant. The D-value of visual analog score in the elderly group was (3.5 ± 3.6), and (2.8 ± 3.5) in the younger group. There was no significant difference in the D-value between the two groups. Five patients had transient minor side effects in the former group and two patients had transient minor side effects in latter group. There was no significant difference in the incidence rate of side effects between the two groups (P > 0.05). Botulinum toxin type A is safe and effective in the treatment of idiopathic trigeminal neuralgia for the patients older than 70 years and the dosages of it are approximate to the patients under 60 years old.

Minimally invasive treatment of lumbar degenerative diseases by anterior lumbar interbody fusion

Objective To explore the clinical efficacy of minimally invasive treatment of lumbar degenerative diseases by anterior lumbar interbody fusion(ALIF). Methods From April 2010 to August 2012, 76 patients with single- level lumbar degenerative diseases were divided into two groups randomly, given ALIF and tranditional posterior lumbar interverbody fusion(PLIF) respectively.The skin incision length,operative time, blood loss and complication were observed.Posterior radiological evaluation was done by MRI image with Taillard index and T2 relaxation time of the operative level on the post- operative month 3.The visual analogue scores(VAS), Oswestry disablility index(ODI) scores and Mac Nab grade were used for clinical assessment. Results All patients were operated successfully and got alleviation of the symptoms to varying degrees.The average skin incision length, the average operative time, the average blood loss and hospital stays were significantly reduced in ALIF group as compared with PLIF group.All cases were followed up for 18- 50 months(average 26.4 months).The complication occurred in 5 cases.At the final followed- up, the radiography showed that 71 cases got bone fusion, and 5 cases got suspicious fusion with the fusion rate being 93.4%.There was significant difference in the average VAS scores and ODI scores between ALIF group and PLIF group in the one- month follow- up.However,at the final follow- up there was no significant difference. Conclusion Minimally invasive treatment of lumbar degenerative diseases by ALIF has the advantages of less invasion, less blood loss, quicker recovery, and less complications.The clinical effect was satisfactory. Key words: Lumbar degenerative diseases; Anterior lumbar interbody fusion; Minimally invasive

Posterior Decompression and Spinopelvic Fixation Using Commercial Pedicle Screw Instead of Iliac Screw for Metastatic Sacral Tumor

Background: Mechanical stabilization of metastatic pathological fracture of the sacrum is technically challenging. There is often inadequate purchase in the sacrum, and instrumentation has to be achieved between the lumbar vertebrae and the ilium. In addition, commercial iliac screws are usually unavailable at most institutes in Taiwan. The purpose of this study is to evaluate the feasibility and efficacy of the original pedicle screw instead of the iliac screw for spinopelvic fixation in patients with metastatic sacral tumor. Methods: From January 2006 to December 2012, we performed posterior decompression and supplemental instrumentation to treat 15 patients with metastatic sacral tumor at our institutes. The original pedicle screw, with 65 mm in length and 7 mm in diameter, was used instead of the iliac screw for spinopelvic fixation. The visual analog score (VAS), modified Brodsky's criteria, Frankel scale, and Oswestry Disability Index (ODI) were recorded before surgery, before discharge, and 6 months after surgery to evaluate the clinical outcomes. Results: The average VAS was 8.1 (range, 7 to 9) before surgery; it significantly decreased to 3.3 (range, 3 to 4) after surgery (p ＜ 0.001), and continued to decrease to 1.9 (range, 1 to 3) at 6 months after surgery (p=0.001). The average ODI measured 82.9% (range, 76% to 92%) before surgery, significantly decreased to 27.2% (range, 20% to 36%) after surgery (p=0.001), and continued to decrease to 20.8% (range, 16% to 28%) 6 months after surgery (p=0.001). All patients achieved a good or excellent outcome based on modified Brodsky's criteria, and the improvement was significant after surgery (p ＜ 0.001). No patient experienced surgery-related complications or neurologic deterioration. Three patients expired due to tumor progression at 10 months, 12 months, and 19 months after surgery. Conclusions: Spinopelvic fixation using commercial pedicle screw and associated neurologic decompression can provide good clinical outcomes and a low complication rate for patients with metastatic sacral tumor.

Cementless femoral revision in patients with a previous cemented prosthesis.

The aim of this study was to evaluate the effectiveness associated with the use of the cementless femoral revision in patients with a previous cemented prosthesis. This study reviewed 92 revision femoral stem performed by a single senior surgeon between January 2006 and December 2012 at our institution. All patients complained of unbearable pain before operation, of which 19 cases had extensively porous-coated revision in Paprosky type I or II femoral defects and 73 had modular tapered revision in type IIIA or IIIB defects. All patients had clinical and radiographic follow-up for an average of 3.9 years (range two to seven years), with a mean age of 62.5 years (range 46-86 years) at surgery. There was no re-revision for loosening. Complications included delayed wound healing in two (2.2 %) patients, dislocation in four (4.3 %), intra-operative femoral fracture in 11 (12.0 %), and periprosthetic fracture postoperatively in three (3.3 %).The average Harris hip scores (HHS) increased from 38.1 (range 20-70) pre-operatively to 82.5 (range 40-95), and the average visual analog scores (VAS) decreased from 8 .3 (range 4-10) pre-operatively to 1.5 (range 0-5) at final follow-up. Radiographic results including stress shielding, subsidence of the stems, bone ingrowth and prosthesis loosening showed that prostheses were stably fixed postoperatively. This supported that cementless fixation, with the use of extensively porous-coated stems or modular tapered stems, was efficient in patients with a previous failed cemented stem.

Acute pain service: the journey in a developing country setting.

In India, acute pain service (APS) is in nascent stage because of lesser importance given to pain management. After establishing an APS in our hospital, we conducted a prospective audit (2008-2011) with an aim to regularly assess the efficacy of techniques on pain scores, muscle power, and adverse effects. The audit was undertaken in three phases. An assessment of the existing system and recommendation to modify the APS was undertaken in phase I. In phase II, an APS team was constituted and audits were conducted at six monthly intervals for formation of the protocol. Subsequently in phase III, yearly audits were undertaken that led to the development of a final APS. There was a steady increase in the number of patients availing APS in intravenous patient-controlled analgesia (IVPCA), epidural analgesia (EA), and continuous peripheral nerve block (CPNB). At the same time, the average visual analogue score (VAS) decreased significantly as the year progressed. While the VAS score did not differ significantly between EA and CPNB, it was less compared with IVPCA. Introduction of regional analgesic techniques played a major role in improving the pain scores. Implementation of APS resulted in reduced pain scores in our surgical patients. Proper planning, role allocation, formation, and adherence to protocols as well as undertaking regular audit resulted in improving the quality of APS.

Intranasal submucosal bevacizumab for epistaxis in hereditary hemorrhagic telangiectasia: A double‐blind, randomized, placebo‐controlled trial

The purpose of this study was to investigate the efficacy of bevacizumab ("Avastin") for the treatment of epistaxis in hereditary hemorrhagic telangiectasia (HHT). In this double blind, placebo controlled trial, 15 adult patients with HHT with a minimum of 2 epistaxis episodes per week were randomized. A history of thromboembolic events or recent or planned surgery led to exclusion. Patients received a single intranasal submucosal injection (10 mL) of 100 mg bevacizumab or placebo. The primary outcome was the relative reduction of average daily epistaxis visual analog score (VAS). Average daily posttreatment VAS scores decreased by 27% in the bevacizumab group and by 3% in the placebo group (p = .57). The reduction in HHT epistaxis severity scores was -0.61 greater in the bevacizumab group compared to the placebo group (p = .34). Results show a trend toward reduced epistaxis with bevacizumab. This further supports the use of bevacizumab in HHT. Clincial Trials. gov number: NCT01314274

Functional outcomes after fixation of "terrible triad" elbow fracture dislocations.

Historically, the published literature on "terrible triad" injuries has shown a high rate of unacceptable results. The use of systematic treatment protocols may improve functional outcome. The authors performed a retrospective study of all patients aged 18 years or older who underwent surgical treatment for "terrible triad" elbow fracture dislocation at their institution over a period 7 years. Surgical treatment involved fixation or replacement of the radial head, repair of the anterior capsule or coronoid fracture in most cases, and repair of the lateral collateral ligament. Outcomes included grip strength, range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, and a visual analog score for pain as well as radiographic assessment of arthritis, maintenance of reduction, and development of heterotopic ossification. Eighteen patients were identified and 11 enrolled. Seven patients had suture fixation of the coronoid fragment and anterior capsule, 2 had screw fixation, and 2 had no repair of the coronoid. The radial head was replaced in 9 patients and repaired in 1, and a fracture fragment was excised in another. The average follow-up was 38 months. The average arc of motion of the injured elbow was 112° and that of the contralateral elbow was 142°. The average DASH score was 19.7 (scale, 0-100). The average visual analog score for pain was 2.2 (scale, 0-10). No patients had recurrent elbow instability. Three patients underwent further surgical procedures, all for loss of motion. The authors concluded that a systematic approach to the fixation of "terrible triad" elbow fracture dislocations can provide predictable elbow stability and functional range of motion in the medium term.

Intracerebroventricular opiate infusion for refractory head and facial pain.

To study the risks and benefits of intracerebroventricular (ICV) opiate pumps for the management of benign head and face pain. SSix patients with refractory trigeminal neuralgia and/or cluster headaches were evaluated for implantation of an ICV opiate infusion pump using either ICV injections through an Ommaya reservoir or external ventricular drain. Four patients received morphine ICV pumps and two patientS received a hydromorphone pump. Of the Four patients with morphine ICV pumps, one patient had the medication changed to hydromorphone. Preoperative and post-operative visual analog scores (VAS) were obtained. Patients were evaluated post-operatively for a minimum of 3 mo and the pump dosage was adjusted at each outpatient clinic visit according to the patient's pain level. All 6 patients had an intracerebroventricular opiate injection trial period, using either an Ommaya reservoir or an external ventricular drain. There was an average VAS improvement of 75.8%. During the trial period, no complications were observed. Pump implantation was performed an average of 3.7 wk (range 1-7) after the trial injections. After implantation, an average of 20.7 ± 8.3 dose adjustments were made over 3-56 mo after surgery to achieve maximal pain relief. At the most recent follow-up (26.2 mo, range 3-56), VAS scores significantly improved from an average of 7.8 ± 0.5 (range 6-10) to 2.8 ± 0.7 (range 0-5) at the final dose (mean improvement 5.0 ± 1.0, P < 0.001). All patients required a stepwise increase in opiate infusion rates to achieve maximal benefit. The most common complications were nausea and drowsiness, both of which resolved with pump adjustments. On average, infusion pumps were replaced every 4-5 years. These results suggest that ICV delivery of opiates may potentially be a viable treatment option for patients with intractable pain from trigeminal neuralgia or cluster headache.

Comparing cold and warm tumescent anesthesia for pain perception during and after the endovenous laser ablation procedure with 1470 nm diode laser

The aim of this study was to compare the pain perception and side effects during and after endovenous laser ablation with a 1470 nm diode laser using cold or room temperature tumescence anesthesia. One hundred and one patients were randomly assigned in two groups. Group A received room temperature (+24℃) and Group B received cold (+4℃) tumescence fluid, which was used for local anesthesia in the track of great saphenous vein. A visual analog score was recorded immediately after the procedure. Patients were asked to register pain scores and the amount of pain medication consumed during the week. There was no significant difference concerning gender, age, Clinical Etiological Anatomical Pathological Classification, body mass index, or diameter of the treated vein. In Group A, the mean linear endovenous energy density was 59.5 J/cm and in Group B, it was 60.4 J/cm. The average visual analog score after the endovenous laser ablation procedure in Group A was 5 and in Group B was 2. Third day after the procedure, the average visual analog score in Group A was 3 and in Group B was 1. Patients in Group B needed significantly less analgesics compared with patients in Group A (p<0.05). The most frequent side effects in both groups were ecchymosis, induration, and minor paraesthesia, all of which were more common in Group A (p < 0.001). To date, most published endovenous laser ablation series describe the use of room temperature tumescence fluid infiltration of the perivenous stroma for tumescent analgesia and protection against thermal injury to the nearby structures. We describe an alternative technique using cold tumescence fluid infiltration, which is equally effective as, but safer than, room temperature tumescence fluid infiltration, and which yields better visual analog scores.

Long‐term control in chronic rhinosinusitis after endoscopic sinus surgery

The concept of control of chronic rhinosinusitis (CRS) has only recently been introduced by the EPOS expert panel following the concept of control in allergic rhinitis and asthma. The aim of this study was to examine the degree of control of CRS at a mean period of 3-5 years after endoscopic sinus surgery (ESS) and to correlate the new criteria of control of CRS to VAS (visual analogue scores) for sinonasal symptoms and the SNOT-22 questionnaire. Another aim was to find out if patients changed from controlled to partly controlled or uncontrolled following nasal endoscopy. All adult patients who had a bilateral ESS procedure for bilateral inflammatory sinonasal disease at the University Hospitals Leuven between January 2008 and December 2010 were contacted by classic mail. They were asked to complete a survey including sinonasal symptoms according to EPOS criteria, VAS scores, SNOT-22 and SF-36 questionnaires and general questions regarding asthma, smoking habits, allergies and current medication intake. They were invited to the out-patient clinic for nasal endoscopy. The response rate was 54.5% (n = 297). 19.8% were well controlled, 39.3% partly and 40.9% uncontrolled. There was no significant difference between the CRSwNP and CRSsNP groups. These results only depended on the self-reported symptoms, without taking into consideration endoscopic examination. Sixty patients underwent endoscopic examination of which 10% were controlled, 30% partly and 60% uncontrolled. The results of the examination showed that 18 patients had signs of recurrence (30%). In 77.8%, the endoscopic findings did not change the degree of control as defined by the questionnaire. 16.7% changed from partly to uncontrolled and 5.6% from controlled to partly controlled. The average global VAS scores of the controlled, partly and uncontrolled groups were 0.8, 2.7 and 5.7 respectively. The average SNOT-22 scores were 9.7, 22.2 and 44.8 respectively. The percentage of partly and uncontrolled CRS greatly overshadows the 19.8% of well controlled CRS. In 77.8% of cases, endoscopic investigation did not change the degree of self-reported control. The sensitivity of the EPOS questionnaire is 94.4% and the specificity is 14.3%. Therefore, endoscopy is useful in lowering the number of false positives. However, as the goal of treatment is the control of symptoms, the value of nasal endoscopy in defining control is one that is debatable.

A prospective review of the labor analgesia programme in a teaching hospital

BackgroundThe structured labor analgesia programme in our tertiary care hospital has been in place for the past few years. We undertook this study to analyze the programme and to draw conclusions to further improve the outcomes. MethodsA prospective analysis of the data pertaining to 200 patients participating in an ongoing labor analgesia programme in a tertiary care hospital from Nov 2008 to Aug 2009 was performed. ResultsMean visual analog score (VAS) before epidural block was 8.34 ± 0.79. Post procedure the average VAS score was 2.20 ± 0.79. One hundred and fifty six (78%) parturients delivered vaginally, 18 (9%) required instrumentation with vacuum including 1 forceps delivery in a multiparous parturient. In 17parturients (8.7%) fetal distress led to a decision to perform LSCS for delivery. Multiparous patients were significantly more satisfied as compared to nulliparous patients (p = 0.010). ConclusionThe study demonstrated excellent pain relief and patient satisfaction with minimal complications. The safety and efficacy of epidural bupivacaine in concentrations less than 0.625% combined with 25 mcg of fentanyl demonstrated in our study should be considered are commendation for the widespread adoption of the procedure in tertiary care hospitals.