Average Visual Analog Scale Pain Score Research Articles

Infiltration Technique for the Fourth FDS Opponensplasty Under WALANT

Background: Wide-awake Local Anesthesia No Tourniquet (WALANT) is a surgical technique that relies on anesthetic and hemostatic agents to provide conditions suitable for hand surgery without sedation and a tourniquet. The opponensplasty using the fourth flexor digitorum superficialis tendon transfer with the pisiform pulley is one of the most used in severe carpal tunnel syndrome patient who is unable to perform thumb opposition due to thenar muscle atrophy with the benefit of small incision, less soft tissue dissection, easy to perform, good esthetic result and has minor morbidity. Key advantages of the pisiform pulley provide balancing abduction and flexion strength of the thumb. To date, there is no report using the WALANT technique for the fourth flexor digitorum superficialis opponensplasty with pisiform pulley. Materials and Method: Between January 2019 and January 2022, 18 patients (4 males and 14 females) with severe carpal tunnel syndrome with thenar muscle atrophy underwent fourth flexor digitorum superficialis opponensplasty as day surgery under the WALANT technique. Operative data, visual analog scale (VAS) pain scores, and complications were recorded. All patients underwent the procedure without any complications. Results: The average age of the patients was 58.4 (43 to 62) year-old. The average operative time was 38.4 (17 to 47) minutes. The average VAS score during the anesthetic injection was 6.43 (4 to -8). The average VAS pain score during the operation was 2.1 (1 to 3). The mean intraoperative blood loss was 3 (2.6 to 6.2) mL. Conclusions: The WALANT technique is safe and can be used as alternative anesthesia for the fourth flexor digitorum superficialis opponensplasty with pisiform pulley. This technique overcomes the problem of judging the appropriate amount of transfer tension by observing awake patients actively. Levels of Evidence: Therapeutic study, level IV

All-suture fixation of syndesmotic injuries: a case series.

To retrospectively evaluate the clinical outcomes of patients treated for syndesmotic injuries with an all-suture construct technique and compare their patient reported outcome scores with historically published outcomes of syndesmotic injuries fixed with suspensory suture buttons. This was a retrospective case series of patients treated at a Level 1 Trauma Center from May 1, 2018, to June 30, 2022. Ten patients aged 18 and older with unstable syndesmotic injuries treated with all-suture repair. Patients were excluded if they were treated with trans-osseous screws, had previous failed syndesmotic fixation, or suspensory suture button fixation. Patient-reported outcomes including Visual Analog Scale (VAS) pain scores, American Orthopaedic Foot and Ankle Society (AOFAS) ankle and hindfoot scores, and complications were recorded. In the patients with 6weeks or more of radiographic follow-up (N = 9), there was no evidence of nonunion, loss of fixation, hardware complication, or whitling of the fibula by the suture. At final follow-up average VAS pain scores were 1.5 out of 10 (range 0-4; SD 1.2), AOFAS ankle and hindfoot scores averaged 89.6 out of 100 (range 86-100; SD 6.1). The pain subscale of the AOFAS score averaged 37.5 out of 40 (range 35-40; SD 2.5). The functional subscale of the AOFAS score averaged 46 out of 50 (range 44-50; SD 3.0). Stiffness was reported in one patient at their follow-up visits, which resolved with continued physical therapy. There were no superficial or deep infections. In conclusion, this case series presents the first clinical outcomes of an all-suture fixation technique for treatment of unstable syndesmotic ankle injuries. Our results suggest that the all-suture fixation technique results in similar patient reported outcomes when compared with historically reported patient reported outcomes of suspensory suture button fixation, and low rates of complication or hardware failure.

Autologous bone plug-sliding with core decompression and bone marrow aspirate concentrate application: a joint-preserving surgical technique for corticosteroid-induced osteonecrosis of femoral head.

This study aimed to describe a surgical procedure for the management of corticosteroid-induced osteonecrosis of the femoral head (ONFH) and report its clinical results. The technique included harvesting a bone plug from the lateral femoral neck, core decompression, and bone marrow aspirate concentrate (BMAC) application; the procedure was completed by press-fit insertion of the autologous bone plug in the debrided area. Autologous bone plug-sliding with core decompression and bone marrow concentrate aspirate application provides good clinical outcomes in the management of ONFH. A retrospective review was performed using records of patients operated on between October 2019 and June 2021. Only patients with Ficat-Arlet stage-2 ONFH, who underwent the procedure described, were included. Twenty- nine hips (18 patients) were included and evaluated clinically and radiologically. Clinical evaluation included the Harris hip score (HHS) and Visual analogue scale (VAS) for pain, while radiological evaluation included direct radiographs. The average age was 39.8 years (± 11.7, range: 24-65 years). The average follow-up was 13.5 months (± 3.4, range: 8-19 months). There were improvements in the VAS pain and Harris hip scores in all patients. Average HHS increased from 61.90 to 87.45 (p < 0.001), while the average VAS pain score decreased from 7.14 to 3.27 (p < 0.001). No complications were encountered in any of the patients during the follow-up. None of the patients had femoral head collapse on the latest radiograph or required total hip replacement. The combination of the novel autologous bone plug-sliding method with conventional regenerative methods is a successful treatment choice for ONFH.

Does preoperative gabapentin or intraoperative ketorolac influence postoperative pain following hip arthroscopy?

Optimization of perioperative analgesia has important implications for patient satisfaction and short-term outcomes. This study's purpose is to assess if preoperative gabapentin or intraoperative ketorolac influences postoperative pain or time to discharge following hip arthroscopy. In total, 409 patients who underwent hip arthroscopic femoroplasty and/or acetabuloplasty with a single surgeon for femoroacetabular impingement were retrospectively reviewed (September 2017 to February 2021). The effect of preoperative gabapentin or intraoperative ketorolac on postoperative visual analog scale (VAS) pain scores, perioperative opioids in morphine milligram equivalents (MMEs), time in post-anesthesia care unit (PACU), second-stage recovery and time to discharge was assessed using unadjusted and adjusted t-tests, and generalized linear models controlling for operative time, traction time, preoperative MME, intraoperative MME and postoperative MME were compared between the groups of gabapentin to no gabapentin and ketorolac to no ketorolac. There was no difference in first PACU VAS pain score, final PACU VAS score, VAS pain score prior to discharge, average VAS pain score or pain level on follow-up call in the unadjusted or adjusted analysis for the preoperative gabapentin or intraoperative ketorolac groups. Females had higher first PACU VAS pain score (6.05 versus 5.15 P = 0.0026), final PACU VAS pain score (4.43 versus 3.90, P = 0.0045), final VAS pain score prior to discharge (3.87 versus 3.03, P < 0.001) and average postoperative pain score (4.60 versus 4.03, P < 0.001), but no difference in VAS pain score on follow-up call following surgery. Gabapentin or ketorolac was not associated with decreased VAS pain scores or time to discharge after hip arthroscopy.

Alignment strategy for different types of varus knee with generic instruments: Mechanical alignment or kinematic alignment?

ObjectiveA thorough examination of the available approaches is crucial to comprehensively understand the variance among the alignment strategies employed in total knee arthroplasty (TKA). In this study, we assessed the functional outcomes during the perioperative and postoperative periods of TKA in patients using generic instruments with varus knee to compare the mechanical alignment (MA) and kinematic alignment (KA) procedures.MethodsA total of 127 patients from the First Affiliated Hospital of Wannan Medical College who had undergone unilateral TKA between November 2019 and April 2021 were included. The patients with varus knee deformity were categorized into two groups [type I (n = 64) and type IV (n = 63)] based on the modified coronal plane alignment of the knee (mCPAK) classification. The type I and IV groups were further subdivided into MA (n = 30 and n = 32) and KA subgroups (n = 34 and n = 21), respectively. The clinical information collected included sex, surgical side, age, body mass index, and perioperative data [including operation time, intraoperative blood loss, length of hospital stay, and the American Society of Anesthesiologists (ASA) classification]. All patients were monitored for 12 months post-surgery to evaluate the recovery of knee joint function. During this period, the Knee Disability and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) and the active range of motion (AROM) and visual analog scale (VAS) pain scores were compared at different time points, i.e., before the operation and 6 weeks, 6 months, and 12 months post-operation. Additionally, the patients’ subjective experiences were assessed at 6 and 12 months post-surgery using Forgotten Joint Score Knee (FJS-12 Knee), while complications were recorded throughout the monitoring period.ResultsNo significant variances were observed in ASA classification, operation duration, blood loss volume during surgery, and hospital stay length between the patients who underwent KA TKA and those who received MA TKA (P > 0.05). During the initial 6 weeks post-operation, the KA group exhibited a significantly reduced average VAS pain score (P < 0.05), with no such differences at 6 months and 1 year after the surgery (P > 0.05). Furthermore, the KA group had significantly higher scores on the KOOS JR at 6 weeks, 6 months, and 1 year following the surgery (P < 0.05). Moreover, the AROM score of the KA group significantly improved only at 6 weeks after the surgery (P < 0.05); however, no prominent differences were found at 6 months and 1 year after the operation (P > 0.05). The KA cohort also exhibited a significant increase in FJS-12 Knee at 1 year following the operation (P < 0.05), whereas no such difference was detected at 6 months following the surgery (P > 0.05). Thus, compared to the MA method, the KA procedure provided pain relief and improved active motion range within 6 weeks after the surgery in patients undergoing TKA. Further, the KOOS JR exhibited significant increases at 6 weeks, 6 months, and 1 year while the FJS-12 Knee demonstrated a significant increase at 1 year after the KA TKA procedure.ConclusionTherefore, our study results suggest that the KA approach can be considered in patients using generic instruments with varus alignment of the knee, particularly those with mCPAK type I and IV varus knees, to help improve patient satisfaction.

Simplified and modified Limberg flap plus vacuum-assisted closure for treatment of sacrococcygeal pilonidal sinus disease.

Pilonidal sinus disease (PSD), a chronic inflammatory disease, affects the sacrococcygeal soft tissue, especially in young adults. The ideal treatment for PSD remains divergence. This study evaluated the application of a simplified modified Limberg flap combined with vacuum-assisted closure for treating PSD. This prospective study was conducted from 1 June 2017 to 31 March 2022 in Changhai Hospital, Naval Military Medical University, Shanghai, China. The study included 88 male patients (91.7%) and 8 female patients (8.3%). The 96 patients ranged in age from 15 to 34 years (mean ± SD, 23 ± 4.4). Under general anaesthesia, all patients underwent simplified modified Limberg flap reconstruction with vacuum-assisted closure. The patient's weight, surgical time, extubation time, hospital stay, time to return to normal life or work, wound infection, wound dehiscence and recurrence rate were recorded. The visual analogue scale (VAS) score and the Vancouver scar score were used to score patients' pain and scars in the surgical area. The volume of resected diseased tissue was 13.5-120 (mean ± SD, 34.993 ± 24.406) cm2 . The average surgical time during the treatment period was 97.68 ± 18.72 min, and the average extubation time was (6.36 ± 1.55) days, the mean hospital stay was 19.4 days; no patients were lost to follow-up. None of the patients experienced post-operative recurrence, wound infection, seroma or hematoma. Six patients (6.3%) experienced wound dehiscence at the flap tip around the natal cleft. The mean time to the resumption of daily activities was 26.3 days. The average VAS pain score was (6.00 ± 1.53) points, and the average Vancouver scar score was (5.96 ± 1.51) points, 12 patients (12.5%) were dissatisfied with their aesthetic results, and the average beauty satisfaction score is (6.64 ± 1.28) points. Simplified modified Limberg flap reconstruction with vacuum-assisted closure surgery is an effective and innovative method for the treatment of PSD, with a low recurrence rate and rapid recovery.

Case Series: Wide-Awake Local Anaesthesia Without Tourniquet (WALANT) for Camitz Transfer.

Background: Wide-Awake Local Anaesthesia Without Tourniquet (WALANT), with the benefit of simplicity and a low complication rate, is a well-recognised procedure in orthopaedic surgery. To date, there is no report using WALANT technique with the Camitz transfer procedure. The aim of this study is to determine the early outcomes of using WALANT for Camitz transfer and compare these with outcomes of similar procedures in literature. Methods: Between January 2012 and January 2018, all patients with severe carpal tunnel syndrome (CTS) with thenar muscle atrophy who underwent the Camitz transfer procedure as day surgery under the WALANT technique at the Thammasat University Hospital were included. With the WALANT technique, the 10 mL of prepared anaesthesia was injected into the area around the palmaris longus tendon from 5-cm proximal to the distal wrist crease to the distal palmar crease, while an additional 10 mL was injected from the radial side of the metacarpophalangeal joint of the thumb to the distal wrist crease before the operation. Upon completion of the operation, the patients' hand was placed in a thumb spica splint. Patient demographic data, visual analogue scale (VAS) during injection and during procedure, operative time, blood lost and complications were recorded. Results: Thirty-six patients (8 males and 28 females) were included. The average age of the patients was 65.9 (37-87) years old. The average VAS score during the anaesthetic injection was 6.22 (5-8). The average VAS pain score during the operation was 0.52 (0-3). The average operative time was 27.06 (17-47) minutes. The mean intraoperative blood loss was 3 (2.4-6.8) mL. All patients underwent the procedure without any complications. Conclusions: The WALANT technique is safe and can be used as alternative anaesthesia for the Camitz transfer. Level of Evidence: Level IV (Therapeutic).

The bared external anal sphincter (BEAS), a new technique for high horseshoe anal fistula: a hospital-based cohort study

The aim of this study was to introduce a new technique, the bared external anal sphincter technique, and to evaluate its effectiveness and safety for primary or recurrent high horseshoe anal fistula (HHAF). We used data from a tertiary referral hospital’s prospective database of a hospital-based cohort. All the patients underwent the bared external anal sphincter procedure. The main outcomes were short‐term clinical outcomes including the 6-month cure rate, Visual Analog Scale pain score (VAS-PS) and Cleveland Clinic Florida incontinence score (CCF-IS). The secondary outcomes included the Quality of Life in Patients with Anal Fistula Questionnaire score (QoLAF-QS), Bristol stool chart and postoperative complications. A total of 48 HHAF patients (39 males) with a mean age of 34.2 years (SD 9.04; range, 21–54) were analyzed in this retrospective study. At the 6-month follow-up, the average VAS-PS and CCF-IS were 0.81 (SD 2.28; range, 0–10) and 1.29 (SD 2.87; range, 0–13), respectively. QoLAF-QS showed that the bared external anal sphincter procedure had no impact over their quality of life in 45 patients (93.75%), limited impact in 2 patients (4.16%), and moderate impact in one patient (2.08%). The Bristol stool scale showed that all patients had normal stool characteristics. The 6-month cure rate was 93.75%. Three patients (6.25%) experienced recurrent symptoms but recovered after surgical management. Urinary retention occurred in 1 case (2.78%). No other postoperative complications were reported. No patient had anal incontinence. The bared external anal sphincter procedure is a safe, effective and sphincter-sparing approach for patients with primary or recurrent HHAF in terms of short‐term results.

Swelling, Stiffness, and Dysfunction Following Proximal Interphalangeal Joint Sprains

Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain. This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy. Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of10. It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains. Prognostic IV.

Clinical Outcomes of Fusion in Type II Accessory Naviculars With or Without Asymptomatic Flatfeet.

Few studies have reported the clinical outcomes of fusion surgeries for type II accessory naviculars. Whether the combination of accessory naviculars and asymptomatic flatfoot will result in worse outcomes in accessory navicular surgeries remains to be elucidated. Our study aims to report the clinical outcomes of fusion for type II accessory naviculars and make a subgroup comparison among accessory navicular patients with or without asymptomatic flatfeet. From May 2017 to June 2021, all painful type II accessory naviculars with or without asymptomatic flatfeet in our inpatient center were reviewed, and those who only underwent fusion surgeries were included in the retrospective study. Visual analog scale (VAS) scores, American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scores, Tegner activity level scores, complications, patient-reported satisfaction, and imaging results (Meary angle in the weightbearing lateral view, talo-first metatarsal angle and talonavicular coverage angle in the weightbearing anteroposterior view) were used to describe outcomes. Thirty-two eligible patients responded to the latest follow-up request and were included in this study. The mean follow-up duration was 37.1 ± 16.0 months. The average VAS pain score improved from 4.7 ± 1.8 preoperatively to 0.9 ± 1.2 at the latest follow-up (P<.001). The average AOFAS midfoot score improved from 67.1 ± 8.5 preoperatively to 90.2 ± 10.7 at the latest follow-up (P<.001). The preoperative and postoperative Tegner activity level scores were similar (3.3 ± 1.5 vs 3.5 ± 1.6, P=.136). The overall complication rate was 37.5%. The most common complication was nonunion (31.3%). The overall satisfaction rate was 90.6%. Similar outcomes were observed between the flatfoot and the nonflatfoot subgroups. Fusion for painful type II accessory naviculars resulted in good symptom relief, function improvement, and patient satisfaction at midterm follow-up, but the nonunion rate was relatively high. Fusion for painful type II accessory naviculars with or without asymptomatic mild to moderate flatfoot brought about similar clinical outcomes. Level III, retrospective comparative study.

Treatment of Hallux Rigidus: Comparison of Hemiarthroplasty with Cartiva Implant, Allograft Interpositional Arthroplasty, and Arthrodesis

Category: Midfoot/Forefoot; Other Introduction/Purpose: Hallux Rigidus (HR) can cause pain with motion, enlarged joint, decreased joint space, subchondral sclerosis, osteophyte formation and restricted joint mobility, limiting patient physical activity. A modern technique for the treatment of HR is 1st MTP hemiarthroplasty with the use of a Cartiva synthetic cartilage implant. The Cartiva implant is designed to imitate natural cartilage; this allows patients to maintain motion in the 1st MTP joint. Current scientific literature reporting early outcomes of the procedure is sparse and mixed. This discrepancy and the overall scarcity of data indicates the need for further analysis. The purpose of this study is to compare improvement in VAS with 1st MTP hemiarthroplasty with the Cartiva implant, allograft interposition arthroplasty and fusion in patients who failed conservative management or cheilectomy. Methods: This study evaluated subjects who underwent interpositional arthroplasty, arthrodesis, or hemiarthroplasty with the Cartiva implant from January 2008 to April 2020, with a minimum of one year documented follow-up. All subjects were 18 years of age and older, diagnosed Hallux rigidus with pain, had a decrease in 1st MTP motion, and had X-ray findings consistent with decreased joint space. Patient data collected includes age, gender, ethnicity, occupation, height, weight, BMI, diabetes status, rheumatoid arthritis status, smoking, co-morbid conditions, medication, activity of choice, duration of symptoms, and operative data. Pre-operative and post- operative Visual Analog Scale (VAS) pain scores were compared between groups. Pain, function, and alignment between groups were also evaluated, pre-operatively and post- operatively, using the AOFAS Midfoot Scale. Secondary objectives evaluated include surgical complications, surgical revision, and X-rays. Results: One hundred patients with 12 months of post-operative follow-up were included in this study: 52 hemiarthroplasty with Cartiva implant patients (Group A), 24 arthrodesis patients (Group B), and 24 interpositional arthroplasty patients (Group C). The mean age of patients was 57.12 years (range 35-95). Average VAS pain scores for Group A was 3.78 (0-9), for Group B was 2.71 (0-10), and Group C was 3.67 (0-8). The average AOFAS score for Group A was 63.36 (30-95), for Group B was 60.98 (32- 83), and Group C was 60.13 (31-83). Pre-operative average VAS pain scores were 4.86 (Group A), 2.32 (Group B), and 5.58 (Group C). Post-operative average VAS pain scores were 2.69 (Group A), 0.91 (Group B), and 1.75 (Group C). Pre-operative average AOFAS scores were 59.52 (Group A), 48 (Group B), and 47.25 (Group C). Post-operative average AOFAS scores were 67.20 (Group A), 73.96 (Group B), and 73 (Group C). Conclusion: Preliminary data shows the greatest reduction in VAS pain scores in the interpositional arthroplasty group. The greatest improvement in derived AOFAS score was seen in the arthrodesis and interpositional arthroplasty groups, indicating a better overall combination of post-operative pain, function, and alignment when compared to patients who underwent hemiarthroplasty with Cartiva implant. While this study is not yet complete, it appears that hemiarthroplasty with Cartiva implant may allow patients to maintain motion in the 1st MTP joint, but at the cost of increased post-operative pain.

Feasibility of quantitative sensory testing in juvenile idiopathic arthritis

ObjectiveJuvenile Idiopathic Arthritis (JIA) is a childhood-rheumatic disease with pain as a major early complaint, and in 10–17% pain remains a major symptom. Very few data exist on sensory threshold changes at the knee in JIA, a location in which inflammation often manifests. We determined whether JIA is associated with sensory threshold changes at the knee by using Quantitative Sensory Testing (QST) and established reference values at the knee of children.MethodsSixteen patients with JIA aged 9–18 years with one affected knee and a patient-reported pain by Visual Analog Scale (VAS) > 10 on a 0–100 scale, and 16 healthy controls completed the study and were included for the analysis. QST was assessed in compliance with the German Research Network on Neuropathic Pain (DFNS) standard. Disease severity was determined using Juvenile Disease Activity Score (JADAS. Perceived pain was assessed with a visual analogue scale(0–100). Feasibility of QST was tested in patients aged 6–9.ResultsUnder the age of 9, QST testing showed not to be feasible in 3 out of 5 JIA patients. Patients with JIA aged 9 and older reported an average VAS pain score of 54.3. QST identified a significant reduction in pressure pain threshold (PPT) and increase in cold detection threshold (CDT) compared to healthy controls. PPT is reduced in both the affected and the unaffected knee, CDT is reduced in the unaffected knee, not the affected knee.ConclusionIn a Dutch cohort of Patients with JIA, QST is only feasible from 9 years and up. Also, sensory threshold changes at the knee are restricted to pressure pain and cold detection thresholds in Patients with JIA.PerspectiveThis article shows that in a Dutch population, the extensive QST protocol is only feasible in the age group from 9 years and older, and a reduced set of QST tests containing at least pressure pain thresholds and cold detection thresholds could prove to be better suited to the pediatric setting with arthritis.

Treatment of Odontoid Fractures in Elderly Patients Using C1/C2 Instrumented Fusion Supplemented With Bilateral Atlantoaxial Joint Spacers: A Case Series.

Spinal fractures are among the most common traumatic injuries in elderly patients, with the odontoid process being frequently affected. As this patient group usually has high rates of comorbidity and chronic diseases, a nonoperative approach may offer a reasonable solution for a favorable fracture pattern. We modified the procedure by implanting a bilateral atlantoaxial joint spacer (model DTRAX) into the joint space and review our experience utilizing this technique for the treatment of patients with a fracture of the odontoid process. A retrospective evaluation was performed on patients treated surgically for unstable traumatic fractures of the odontoid process. The stabilization was performed using a dorsal rod and screw instrumentation of the lateral mass of the atlas and the pars interarticularis of the axis. The procedure was further modified by implanting a bilateral atlantoaxial joint spacer (DTRAX) into the joint space bilaterally after the removal of the articular cartilage. Patients older than 70 years with a traumatic fracture of the odontoid process were included. Pain was assessed pre- and postoperatively using the visual analog scale (VAS). To verify fusion during follow-up, either x-ray imaging of the cervical spine or magnetic resonance imaging or computed tomography were performed. A total of 5 patients were included in our study. Four patients had an American Society of Anesthesiology score of 3 and 1 had a score of 4. The average duration of surgery was 187 ± 38.1 minutes. The average blood loss during the procedure was 340 ± 270 mL. The average radiological follow-up period was 21.2 ± 17.5 months. Preoperatively, the average VAS pain score was 2.3 ± 3.3. Postoperatively, the mean VAS decreased to 0.6 ± 0.9. The average follow-up period for pain was 27.2 ± 19 months. No patient showed neurological deficits before or after surgery. Follow-up demonstrated solid fusion in all cases. The fusion of the atlantoaxial joint with bilateral atlantoaxial joint spacers represents a suitable and feasible option for achieving high fusion rates in elderly patients with odontoid fractures. A significant percentage of patients who are treated non-operatively will experience nonunion, which may cause instability of the atlantoaxial joint. Posterior fixation with screws and rods is a treatment option, but it leaves the cartilaginous joint surface in place, which can be an impediment to the fusion process. In other cases, degenerative collapse of the C1/C2 joint can cause compression of the C2 nerve root.

Nerve transfers for femoral nerve palsy: an updated approach and surgical technique.

Femoral nerve palsy results in significant impairment of lower extremity function due to the loss of quadriceps muscle function. The authors have previously described their techniques utilizing the anterior obturator and sartorius nerves for transfer in cases of femoral nerve palsy presenting within 1 year of injury. In the current study, the authors discuss their updated techniques, results, and approach to partial and complete femoral nerve palsies using femoral nerve decompression and nerve transfers. They conducted a retrospective review of patients with femoral nerve palsies treated with their technique at the Washington University School of Medicine in 2008-2019. Primary outcomes were active knee extension Medical Research Council (MRC) grades and visual analog scale (VAS) pain scores. Fourteen patients with femoral nerve palsy were treated with femoral nerve decompression and nerve transfer: 4 with end-to-end (ETE) nerve transfers, 6 with supercharged end-to-side (SETS) transfers, and 4 with ETE and SETS transfers, using the anterior branch of the obturator nerve, the sartorius branches, or a combination of both. The median preoperative knee extension MRC grade was 2 (range 0-3). The average preoperative VAS pain score was 5.2 (range 1-9). Postoperatively, all patients attained an MRC grade 4 or greater and subjectively noted improved strength and muscle bulk and more natural gait. The average postoperative pain score was 2.3 (range 0-6), a statistically significant improvement (p = 0.001). Until recently, few treatments were available for high femoral nerve palsy. A treatment strategy involving femoral nerve decompression and nerve transfers allows for meaningful functional recovery and pain relief in cases of partial and total femoral nerve palsy. An algorithm for the management of partial and complete femoral nerve palsies and a detailed description of surgical techniques are presented.

Radiographic and Clinical Outcomes of Non-Operative Treatment for Patients with Non-Union of Fractures of the Mid-Shaft of the Clavicle in Adults.

Background: Non-unions of clavicle fracture after conservative treatment have been treated surgically, but carry a risk of complications. The aim of this study is to report the outcomes of non-operative treatment for patients with non-union of fractures of the mid-shaft of the clavicle following initial conservative treatment. Methods: This is a retrospective study done at a single centre. Subjects with non-union after conservative treatment of clavicle mid-shaft fractures between March 2004 and February 2019 were included in this study. The exclusion criteria included follow-up period <1 year after the diagnosis of non-union and concomitant upper extremity injury. Final radiographs were assessed for fracture healing, vertical displacement, and shortening. Visual analog scale (VAS) pain scores, shoulder range of motion (ROM) and self-rated outcomes were obtained. Results: Fourteen patients (five females) with an average age of 58 (range, 29-76) years and a mean follow-up duration of 4.0 (range, 1.5-10.2) years were included in the study. The average vertical fracture displacement was 188.7 (range, 95.4-301.4) percent and the average shortening was 13.2 (range, 2.7-16.9) percent. The average VAS pain score was 0.21 (range, 0-2) points. There was no significant difference in the ROM between the injured and uninjured shoulder (p = 0.715 for forward flexion, 0.070 for abduction and 0.714 for external rotation) and the Constant shoulder score (p = 0.190). Thirteen of the 14 patients were satisfied with the treatment, and 12 returned to their pre-injury level of sports participation. Conclusions: Non-operative treatment resulted in a favourable outcome for patients with non-union of clavicle fracture after conservative treatment. Self-rated outcome score was excellent, regardless of the presence of radiographic abnormalities. Level of Evidence: Level IV (Therapeutic).

Endoscopic Treatment of Piriformis Syndrome Results in a Significant Improvement in Pain Visual Analog Scale Scores

PurposeTo survey the clinical satisfaction of patients who have had an endoscopic piriformis release with a sciatic nerve neurolysis.MethodsPatients with piriformis syndrome (PS) who were treated with an endoscopic piriformis release combined with a sciatic neurolysis between 2013 and 2018 were identified. All patients had a minimum follow-up of 1 year. Patients were contacted by telephone in 201,9 whereby the rate of satisfaction and pain were evaluated with the Benson surgery scale and the visual analog scale (VAS).ResultsThe average duration of symptoms at first presentation was 34 months (range 16-54 months). Thirty-seven cases (82,2%) had an EMG that showed sciatic compression around the piriformis muscle. The average preoperative VAS pain score was 7.4 (± 0.8). The mean VAS score at the time of the survey was 1.9 (± 2.4). The difference in median preoperative and postoperative VAS was 6. Using the Wilcoxon signed-rank test, we found there was a significant improvement of VAS score (with P < .001). Using the Benson operative scale, we found that outcomes at the time of the survey were excellent in 23 patients (24 cases, 53.4%), good in 10 (22.2%), fair in 3 (6.7%), and poor in 8 (17.7%). Three patients with a poor result had a wrong diagnosis of PS and ended up needing treatment for a different diagnosis. In total, 33 patients answered affirmative on the question if they would undergo the procedure again. Apart from 3 local wound infections, no major complications were observed.ConclusionsOnce a diagnosis is made, the endoscopic release of the piriformis tendon results in significant improvement in Pain VAS scores for patients with refractory symptoms despite conservative treatment.Level of EvidenceLevel IV, therapeutic case series.

In Situ Neurolysis of Ulnar Nerve for Patients With Failed Anterior Subcutaneous Transposition - A Case Series.

BACKGROUNDVarious surgical techniques have been attempted to treat patients with failed anterior subcutaneous transposition performed for cubital tunnel syndrome.OBJECTIVETo analyze intraoperative findings of failed anterior subcutaneous transposition and to report the outcome of in Situ neurolysis of ulnar nerve.METHODSPatients who, under diagnosis of failed anterior subcutaneous transposition of ulnar nerve, underwent in Situ neurolysis between 2001 and 2018 were included in this study. We excluded patients with follow-up of less than one year, records of traumatic ulnar nerve injury, and concomitant double crush syndrome such as cervical spondylosis causing radicular pain, ulnar tunnel syndrome, or thoracic outlet syndrome. Surgical outcomes were evaluated using visual analog scale (VAS) pain score and Disabilities of the Arm, Shoulder, and Hand (DASH) score, which were assessed before and after surgery. A total of 28 elbows in 27 patients whose average age was 58.5 (range, 31-76) yr were enrolled, and the duration of follow-up was 5.8 (range, 1.0-14.9) yr.RESULTSThe most common pathologic finding identified during operation was severe adhesion of the transposed nerve in all elbows, followed by incomplete decompression of deep flexor-pronator aponeurosis in 26 elbows (93%). The average VAS pain score improved from 4.9 (range, 2-7) to 1.3 (range, 0-5), and the average DASH score from 31.7 (range, 18.1-66.7) to 14.1 (range, 5.0-46.6). Of the 28 elbows, 27 (96.4%) showed improvement of preoperative symptoms.CONCLUSIONIn Situ neurolysis of ulnar nerve for patients with failed anterior subcutaneous transposition resulted in satisfactory outcome.

Enhanced Recovery After Surgery Protocol Minimizes Intensive Care Unit Utilization and Improves Outcomes Following Pulmonary Resection.

BackgroundEnhanced recovery after surgery (ERAS) protocols have been associated with improved postoperative outcomes but require further validation in thoracic surgery. This study evaluated outcomes of patients undergoing pulmonary resection before and after implementation of an ERAS protocol.MethodsElectronic medical records were queried for all patients undergoing pulmonary resection between April 2017 and April 2019. Patients were grouped into pre- and post-ERAS cohorts based on dates of operation. The ERAS protocol prioritized early mobilization, limited invasive monitoring, euvolemia, and non-narcotic analgesia. Primary outcome measures included intensive care unit (ICU) utilization, postoperative pain metrics, and perioperative morbidity. Regression analyses were performed to identify predictors of morbidity. Subgroup analyses were performed by pulmonary risk profile and surgical approach.ResultsA total of 64 pre- and 67 post-ERAS patients were included in the study. ERAS implementation was associated with reduced postoperative ICU admission (pre: 65.6% vs. post: 19.4%, p < 0.0001), shorter ICU median length of stay (LOS) (pre: 1 vs. post: 0, p < 0.0001), and decreased opioid usage measured by median morphine milligram equivalents (pre: 40.5 vs. post: 20.0, p < 0.0001). Post-ERAS patients also reported lower visual analog scale (VAS) pain scores on postoperative days (POD) 1 and 2 (pre: 6.3/5.6 vs. post: 5.3/4.2, p = 0.04/0.01) as well as average VAS pain score over POD0-2 (pre: 6.2 vs. post: 5.2, p = 0.005).ConclusionsImplementation of an ERAS protocol for pulmonary resection, which dictated reduced ICU admissions, did not increase major postoperative morbidity. Additionally, ERAS-enrolled patients reported improved postoperative pain control despite decreased opioid utilization.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00268-021-06259-1.

Adductor Canal Block vs Liposomal Bupivacaine Periarticular Injection in Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundThis study compares postoperative pain scores and functional outcomes between liposomal bupivacaine peri-articular injection (LB-PAI) vs a single-shot adductor canal block (ACB) using bupivacaine HCl in patients undergoing primary total knee arthroplasty (TKA). MethodsThis is a randomized controlled trial of 56 patients who were treated with TKA for arthritis. Patients were randomized to receive an intraoperative LB-PAI (n = 27) or preoperative ACB using bupivacaine HCl (n = 29). Both groups were otherwise given our institutional standard multimodal pain protocol. Data on Visual Analog Scale (VAS) pain scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, knee range of motion, postoperative ambulation distance, hospital length of stay, and opioid use were collected. The total cost of each intervention was compared at the conclusion of the study. ResultsAge, gender, or body mass index was similar between groups. Compared to the ACB group, the LB-PAI group trended to lower average VAS pain scores on postoperative days 0, 1, and 2 (average difference [95% confidence interval] = −0.5 [−0.7, 1.7], −1.0 [−0.1, 2.0], −0.2 [−0.8, 1.3]), and identical average VAS pain scores on postoperative days 4 and 7. These differences and all postoperative outcome measures were not statistically significant at any time point. A single 266-milligram vial of liposomal bupivacaine costs $351, and a single-shot ACB costs $893 at our institution. ConclusionsThis randomized controlled trial shows similar postoperative pain control, functional outcomes, and opioid use between LB-PAI and a single-shot ACB in patients undergoing primary TKA. However, the single-shot ACB costs $542 more than the LB-PAI at our institution.

Assessment of pain, anxiety and depression, and quality of life after minimally invasive aortic surgery

Minimally invasive cardiac surgery may reduce surgical trauma, diminish postoperative pain and improve quality of life (QOL). The aim of this study is to assess pain, hospital anxiety and depression scale (HADS), and QOL in patients undergoing minimally invasive aortic surgery. This is a prospective, single-center cohort study of 24 consecutive patients undergoing upper ministernotomy aortic valve, aortic root, and concomitant aortic valve and ascending aorta replacement. Visual analog scale (VAS) pain scores and HADS and Short-Form-36 (SF-36) questionnaires were evaluated at preoperative baseline, during hospitalization, and at 1 and 3 months postoperatively. At discharge, the average VAS pain score was significantly lower than postoperative Day 1 (2.7 ± 0.4 vs. 6.5 ± 0.4; p ≤ .001). By 1 month, the pain scores were not significantly different from baseline (1.7 ± 0.4 vs. 1.0 ± 0.4; p = 1.000), and by 3 months, pain scores returned to baseline (1.0 ± 0.4; p = 1.000). HADS scores show that compared with preoperative baseline, average anxiety scores decreased by 1 month (3.1 ± 0.7 vs. 4.3 ± 0.6; p = 1.000) and decreased significantly by 3 months (1.8 ± 0.7 vs. 4.3 ± 0.6; p = .012). Additionally, depression scores were unchanged at 1 month (3.0 ± 0.4 vs. 3.1. ± 0.4; p = 1.000) and decreased by 3 months (1.3 ± 0.5 vs. 3.0 ± 0.4; p = .060). SF-36 scores revealed no changes in scores in 7 of 8 domains at 1 month and a significant increase in "physical functioning," "energy," and "general health" domains compared to preoperative baseline at 3 months. Following minimally invasive aortic surgery, VAS pain scores, HADS and scores in 7 of 8 SF-36 domains returned to preoperative baseline or improved compared to preoperative baseline at 1 month. At 3 months, scores in 3 of 8 SF-36 domains significantly improved compared to preoperative baseline. Larger studies are necessary for further investigation.