Cutaneous Nerve Research Articles

Lateral Femoral Cutaneous Nerve Block or Wound Infiltration Combined with Pericapsular Nerve Group (PENG) Block for Postoperative Analgesia following Total Hip Arthroplasty through Posterior Approach: A Randomized Controlled Trial.

Background: Pericapsular nerve group (PENG) block, although effective for pain management following total hip arthroplasty (THA), does not cover skin analgesia. In this randomized controlled trial, we compared the effectiveness of PENG block combined with lateral femoral cutaneous nerve (LFCN) block or wound infiltration (WI) on postoperative analgesia and functional outcomes. Methods: Fifty patients undergoing posterior-approached THA under spinal anesthesia were randomly allocated to receive LFCN block with 10 mL of 0.5% ropivacaine or WI with 20 mL of 0.5% ropivacaine. In both groups, PENG block was performed by injecting 20 mL of 0.5% ropivacaine. Primary outcomes were static and dynamic pain scores (0-10 numeric rating scale) measured in the first 24 h after surgery. Secondary outcomes included postoperative opioid consumption, functional assessment and length of hospital stay. Results: Postoperative static NRS of patients receiving LFCN was higher than that of patients receiving WI at 6 h but lower at 24 h, with a median (IQR) of 3 (2-4) vs. 2 (1-2) (p < 0.001) and 2 (2-3) vs. 3 (3-4) (p = 0.02), respectively. Static pain scores at 12 h did not show significant differences, with an NRS of 3 (2-4) for WI vs. 3 (3-4) for LFCN (p = 0.94). Dynamic pain and range of movement followed a similar trend. No significant differences were detected in other outcomes. Conclusions: LFCN block was not inferior to WI for postoperative analgesia and functional recovery in association with PENG block during the first postoperative day, although it had worse short-term pain scores. Based on these results, it is reasonable to consider LFCN block as a valid alternative to WI or even a complementary technique added to WI to enhance skin analgesia during the first 24 h after THA. Future studies are expected to confirm this hypothesis and find the best combination between PENG block and other techniques to enhance analgesia after THA.

Single-Dose Intravenous Tranexamic Acid Does Not Increase Venous Thromboembolic Rate or Complication Rate During Hip Arthroscopy

To determine whether tranexamic acid (TXA) is safe to administer preoperatively in patients undergoing hip arthroscopy by comparing the venous thromboembolic rate and complication rate between patients who did and did not receive TXA preoperatively. This was a multicenter consecutive-cohort series of patients who underwent arthroscopic hip surgery between 2014 and 2021. The 2 cohorts comprised patients who did and did not receive TXA preoperatively (single dose of 1-2 g), after a practice change. Data were collected via chart review. Surgical outcomes included days until follow-up, visual analog scale pain score at first follow-up, total operating room (OR) time, number of arthroscopic fluid bags (3 L/bag), and complications and revision operations up to 1 year after surgery. The Mann-Whitney U test was performed for continuous variables, and the χ2 test, for categorical variables. A total of 862 patients were identified: 449 (52%) received TXA and 413 (48%) did not. Patient demographic characteristics including age, sex, height, weight, body mass index, smoking status, and procedures performed, as well as number of anchors used (3.5 anchors for no TXA vs 3.7 anchors for TXA) and traction time (38 minutes for no TXA vs 40 minutes for TXA), did not significantly differ between groups. Significantly more patients underwent prior hip arthroscopy in the TXA group (n= 45; primary, n=404) than in the group that did not receive TXA (n= 25; primary, n= 388) (P= .03). Visual analog scale pain scores at the first follow-up visit (2.61 for no TXA vs 2.62 for TXA, P= .62) and the need for subsequent revision surgery (24 patients with no TXA vs 18 patients with TXA, P= .68) were not significantly different. TXA use was associated with less arthroscopic fluid utilization (5.9 bags of 3 L of fluid for no TXA vs 5.3 bags of 3 L of fluid for TXA, P < .01) and less total OR time (99.5minutes for no TXA vs 90.0 minutes for TXA, P < .01). There was a higher overall complication rate in the group that did not receive TXA (n= 27) than in the group that did (n= 10) (P= .01). However, if lateral femoral cutaneous nerve neurapraxia was excluded, then no difference in complication rate was observed (P= .24). There was no difference in the incidence of venous thromboembolic complications between patients who did and did not receive TXA preoperatively. We observed a lower overall complication rate in patients who received TXA preoperatively; however, this normalized between the 2 groups when lateral femoral cutaneous nerve neuritis was excluded. No difference in early pain control or revision surgery rate was observed between groups. Although there was statistically less arthroscopic fluid utilization and less total OR time in the group that received TXA, further studies are needed to clarify whether this is clinically meaningful. Preoperatively administered TXA is a safe adjunct medication in patients undergoing arthroscopic hip surgery. Level III, retrospective multicenter consecutive series.

Denervation procedure of the lateral epicondyle for refractory lateral epicondylitis

BackgroundLateral epicondylitis is the most common cause of lateral elbow pain in adults, and non-operative treatment is the first-line management modality of choice. Pain refractory to conservative management may improve with surgical interventions involving ECRB débridement or denervation. This investigation was conducted to evaluate the long-term analgesic efficacy, incidence of postoperative sensory deficits, and postoperative elbow functionality in patients who underwent a denervation surgery of the posterior branch of the posterior cutaneous nerve of the forearm (PBPCNF) for refractory lateral epicondylitis. MethodsThis investigation was an IRB-approved, single-center, single-surgeon case series of 22 patients who underwent denervation surgery with an average final follow-up of 4.7 years. Inclusion criteria for surgery were a minimum of 6 months symptom duration refractory to conservative therapies, a minimum of 2 years clinical follow-up, and significant (70-80%) pain relief from the nerve block test. Visual Analog Scale (VAS) pain and Single Assessment Numerical Evaluation (SANE) scores were used to assess pain and function, respectively. The incidence of postoperative sensory deficits was evaluated via clinical exam. ResultsCompared to the preoperative average, the cohort’s mean VAS pain was significantly decreased at all postoperative follow-up intervals, including 2 weeks, 1 year, and final average follow-up of 4.7 years. At the final follow-up, the mean SANE score was 98.8 ± 2.6, and one patient (4.5%), who reported the same sensory deficit preoperatively, reported postoperative sensory deficits. ConclusionsThe PBPCNF denervation procedure is a highly efficacious procedure for achieving long-term pain control in the treatment of refractory lateral epicondylitis. The PBPCNF denervation procedure affords patients a high level of postoperative functionality with a low incidence of sensory deficits.

Immunohistochemical and histopathological analyses of cutaneous innervation to improve the diagnostic efficacy in hansen disease skin lesion

Abstract Background The diagnosis of Hansen disease (HD) can be difficult when acid-fast bacilli are not detected in the patient's skin sample. Objective To demonstrate that detailed morphological analysis of nonspecific inflammatory and/or noninflammatory alterations in dermal nerves as well as skin adnexa in leprosy-suspected biopsy samples could improve the efficacy of histopathological diagnosis. Methods Patients with one to five skin lesions were enrolled in the study and classified into three groups by skin histopathology findings: Hansen disease (HD, n = 13), other diseases (OD, n = 11), and inconclusive cases (INC, n = 11). We quantified dermal nerve damage via the nerve lesion index (NLI) and PGP9.5-immunoreactive axon quantitative index in dermal nerves (AQI). We also measured inflammatory involvement of adnexa in cutaneous samples as indirect evidence of HD. Results We observed a higher median endoneurial inflammatory infiltrate NLI (HD = 0.5; INC = 0; OD = 0; p &lt; 0.001) and more frequent inflammatory involvement of skin adnexa in samples of the HD group compared with those of the INC and OD groups (HD = 7; INC = 1; OD = 0). However, samples from the INC and OD groups also showed inflammatory and noninflammatory damage of dermal nerves, with 2 or more kinds of alterations in nerves in the same sample (respectively: INC = in 1 and 2 samples; OD = in 3 and 5 respectively). The quantification of PGP9.5-immunoreactive axons in dermal nerves revealed no difference between the groups. Conclusion A detailed morphological analysis of cutaneous nerves in lesions with a suspicion of HD enabled us to select patients with nonspecific inflammatory or non-inflammatory lesions in the dermal nerves in the INC and OD groups, so they may be clinically monitored aiming at a possible future diagnosis of the disease. These INC and OD patients cannot have the HD diagnosis definitely excluded, and HD may coexist with another disease as a comorbidity.

Incidence and clinical outcome of lateral femoral cutaneous nerve injury after periacetabular osteotomy.

Lateral femoral cutaneous nerve (LFCN) injury is a complication after periacetabular osteo-tomy (PAO) using an anterior approach, which might adversely affect the outcome. However, no prospective study has assessed the incidence and severity of this injury and its effect on the clinical outcomes over a period of time for longer than one year after PAO. The aim of this study was to assess the incidence and severity of the symptoms of LFCN injury for ≥ three years after PAO and report its effect on clinical outcomes. A total of 40 hips in 40 consecutive patients who underwent PAO between May 2016 and July 2018 were included in the study, as further follow-up of the same patients from a previous study. We prospectively evaluated the incidence, severity, and area of symptoms following LFCN injury. We also recorded the clinical scores at one year and ≥ three years postoperatively using the 36-Item Short Form Health Survey (SF-36) and Japanese Orthopaedic Association Hip Disease Evaluation Questionnaire (JHEQ) scores. A total of 20 patients (50%) had symptoms of a LFCN injury at one year after PAO. At ≥ three years postoperatively, the symptoms had completely resolved in seven of these patients and 13 (33%) had persistent symptoms. The severity and area of symptoms did not significantly differ between one and ≥ three years postoperatively. The JHEQ showed significant differences in the patient satisfaction and mental scores between those with and those without sypmtoms of LFCN injury at ≥ three years postoperatively, while there was no significant difference in the mean SF-36 scores. The incidence of LFCN injury after PAO using an anterior approach is high. The outcome of PAO, ≥ three years postoperatively, is poorer in patients with persistent symptoms from a perioperative LFCN injury, in that patient satisfaction and mental health scores are adversely affected.

Enhancing postoperative recovery in total hip arthroplasty: the role of pericapsular nerve group and lateral cutaneous nerve block under spinal anaesthesia.

To compare the efficacy of spinal anaesthesia alone versus spinal anesthesia augmented with ultrasound-guided pericapsular nerve group (PENG) block combined with lateral femoral cutaneous nerve (LFCN) block in improving perioperative analgesia and functional recovery in patients undergoing THA. In a prospective, randomized clinical trial we included 66 patients scheduled for THA were divided into two groups: one receiving spinal anaesthesia alone (SA group; n = 32) and the other receiving spinal anaesthesia with regional analgesia blocks PENG + LFCN (SRAB group; n = 34). In the SRAB group, PENG followed by LFCN blocks were administered under ultrasound guidance before spinal anaesthesia. There were significant differences between the two groups in the onset of postoperative pain (p < 0.01) and the total amount of analgesics required in the first 36 postoperative hours (p < 0.01). The combined approach of spinal anaesthesia with PENG and LFCN blockade, enables opioid-free analgesia and may contribute to a safer and more comfortable postoperative experience for THA patients.

Relationship to the superficial radial nerve and anatomic variations of the first extensor compartment in Thai population: a basis for successful de Quervain tenosynovitis treatment.

Knowledge of the superficial radial nerve (SRN) relationship and anatomic variations of the first extensor compartment (1st EC) will contribute to a better outcome of de Quervain tenosynovitis treatment. We dissected 87 embalmed cadaveric wrists to determine the relationship of the SRN, the 1st EC length, distance from the proximal and distal 1st EC borders to radial styloid process (RSP), abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon slip numbers, and the presence of septum. Our results revealed SRN crossing over the 1st EC in 59.5%. The lateral branch of the superficial radial nerve to the 1st EC midline in most cases (61.9%) except for one specimen, where lateral antebrachial cutaneous nerve was the closest. Distances from proximal and distal 1st EC borders to the RSP were 19.7±4.1 mm and 7.6±1.8 mm, respectively. Extensor retinaculum (ER) width over 1st EC (1st EC length) was 14.8±3.2 mm. Complete and incomplete septa were found in 17.2%, and 42.5%, respectively. The most frequent APL tendon slip number in the compartment was two in overall 47 specimens (54.0%). Almost all compartments (85 specimens; 97.7%) contained one EPB tendon slip. We detected bilateral EPB absence in one cadaver. Moreover, we recorded a tendon slip from extensor pollicis longus traveling into 1st EC bilaterally in one cadaver and observed the EPB muscle belly extension into 1st EC in 9 wrists. Awareness of 1st EC anatomic variations would be essential for successful surgical and nonsurgical outcomes.

Fascia Iliaca Catheters for Donor Site Pain After Split-Thickness Skin Grafting for Acute Burn Injury: A Retrospective Review.

The management of acute burn pain poses significant challenges. Regional techniques have become increasingly popular in perioperative burn pain management. Continuous nerve block catheters are particularly useful for split-thickness skin grafts where donor site pain can exceed that of the burn-injured site. Donor skin is frequently harvested from the anterolateral thigh. The fascia iliaca (FI) compartment block provides blockade of both the lateral femoral cutaneous nerve and the femoral nerve, and thus, it is a useful modality for burn donor pain. Our institution initiated a protocol in which continuous FI catheters were placed in patients undergoing split-thickness skin grafting of the anterolateral thigh. This retrospective review seeks to assess the impact of this modality on postoperative pain scores and opioid requirements. Oral morphine equivalent (OME) administration was significantly lower in the FI group than the control group, starting with POD 0, which is the day of the FI catheter insertion (188 vs 327 mg, P < .001). Over the next 4 postoperative days (PODs), OME administration remained lower in the FI group compared to control patients, although not statistically significant on PODs 3-4. There was a significant difference in OME administered between the FI group and the control group on POD 5 (159.5 vs 209.2 mg, P < .05). Our retrospective study evaluating the role of FI catheters in burn patients undergoing split-thickness skin grafting surgery showed significantly lower opioid consumption on PODs 1-5 compared to patients without an FI catheter.

The Effects of the Pericapsular Nerve Group Block on Postoperative Pain in Patients with Hip Fracture: A Multicenter Study.

An adequate early mobilization followed by an effective and pain-free rehabilitation are critical for clinical and functional recovery after hip and proximal femur fracture. A multimodal approach is always recommended so as to reduce the administered dose of analgesics, drug interactions, and possible side effects. Peripheral nerve blocks should always be considered in addition to spinal or general anesthesia to prolong postoperative analgesia. The pericapsular nerve group (PENG) block appears to be a less invasive and more effective analgesia technique compared to other methods. We conducted multicenter retrospective clinical research, including 98 patients with proximal femur fracture undergoing osteosynthesis surgery within 48 h of occurrence of the fracture. Thirty minutes before performing spinal anesthesia, 49 patients underwent a femoral nerve (FN) block plus a lateral femoral cutaneous nerve (LCFN) block, and the other 49 patients received a PENG block. A non-parametric Wilcoxon-Mann-Whitney (α = 0.05) test was performed to evaluate the difference in resting and dynamic numerical rating scale (NRS) at 30 min, 6 h, 12 h, and 24 h. the PENG block administration was more effective in reducing pain intensity compared to the FN block in association with the LFCN block, as seen in the resting and dynamic NRS at thirty minutes and 12 h follow-up. the PENG block was more effective in reducing pain intensity than the femoral nerve block associated with the lateral femoral cutaneous nerve block in patients with proximal femur fracture undergoing to osteosynthesis.

A Novel Approach to Facial Reanimation and Restoration Following Radical Parotidectomies.

Background: Parotidectomies are indicated for a variety of reasons. Regardless of the indication for surgery, facial reanimation may be required because of facial nerve sacrifice or iatrogenic damage. In these cases, facial restoration performed concurrently with ablative surgery is considered the gold standard, and delayed reanimation is usually not attempted. Methods: A retrospective review of all patients who underwent parotidectomies from 2009 to 2022 in a single institution was performed. Indications, surgical techniques, and outcomes of an algorithmic template were applied to these cases using the Sunnybrook, Terzis scores, and Smile Index. A comparison was made between immediate vs. late repairs. Results: Of a total of 90 patients who underwent parotidectomy, 17 (15.3%) had a radical parotidectomy, and 73 (84.7%) had a total or superficial parotidectomy. Among those who underwent complete removal of the gland and nerve sacrifice, eight patients (47.1%) had facial restoration. There were four patients each in the immediate (n = 4) and late repair (n = 4) groups. Surgical techniques ranged from cable grafts to vascularized cross facial nerve grafts (sural communicating nerve flap as per the Koshima procedure) and vascularized nerve flaps (chimeric vastus lateralis and anterolateral thigh flaps, and superficial circumflex perforator flap with lateral femoral cutaneous nerve). Conclusions: The algorithm between one technique and another should take into consideration age, comorbidities, soft tissue defects, presence of facial nerve branches for reinnervation, and donor site morbidity. While immediate facial nerve repair is ideal, there is still benefit in performing a delayed repair in this algorithm.

Insights on the Choice and Preparation of the Donor Nerve in Corneal Neurotization for Neurotrophic Keratopathy: A Narrative Review.

The article introduces neurotrophic keratopathy (NK), a condition resulting from corneal denervation due to various causes of trigeminal nerve dysfunctions. Surgical techniques for corneal neurotization (CN) have evolved, aiming to restore corneal sensitivity. Initially proposed in 1972, modern approaches offer less invasive options. CN can be performed through a direct approach (DCN) directly suturing a sensitive nerve to the affected cornea or indirectly (ICN) through a nerve auto/allograft. Surgical success relies on meticulous donor nerve selection and preparation, often involving multidisciplinary teams. A PubMed research and review of the relevant literature was conducted regarding the surgical approach, emphasizing surgical techniques and the choice of the donor nerve. The latter considers factors like sensory integrity and proximity to the cornea. The most used are the contralateral or ipsilateral supratrochlear (STN), and the supraorbital (SON) and great auricular (GAN) nerves. Regarding the choice of grafts, the most used in the literature are the sural (SN), the lateral antebrachial cutaneous nerve (LABCN), and the GAN nerves. Another promising option is represented by allografts (acellularized nerves from cadavers). The significance of sensory recovery and factors influencing surgical outcomes, including nerve caliber matching and axonal regeneration, are discussed. Future directions emphasize less invasive techniques and the potential of acellular nerve allografts. In conclusion, CN represents a promising avenue in the treatment of NK, offering tailored approaches based on patient history and surgical expertise, with new emerging techniques warranting further exploration through basic science refinements and clinical trials.

Superficial branch of the radial nerve regularly contains fibers from the lateral antebrachial cutaneous nerve: A role in neuroma treatment

BackgroundMany surgical strategies aim to treat the symptomatic neuroma of the superficial branch of the radial nerve (SBRN). It is still difficult to treat despite many attempts to reveal a reason for surgical treatment failure. The lateral antebrachial cutaneous nerve (LACN) is known to overlap and communicate with SBRN. Our study aims to determine the frequency of spreading of LACN fibers into SBRN branches through a microscopic dissection to predict where and how often LACN fibers may be involved in SBRN neuroma. MethodsEighty-seven cadaveric forearms were thoroughly dissected. The path of LACN fibers through the SBRN branching was ascertained using microscopic dissection. Distances between the interstyloid line and entry of LACN fibers into the SBRN and emerging and bifurcation points of the SBRN were measured. ResultsThe LACN fibers joined the SBRN at a mean distance of 1.7 ± 2.5 cm proximal to the interstyloid line. The SBRN contained fibers from the LACN in 62% of cases. Most commonly, there were LACN fibers within the SBRN’s third branch (59%), but they were also observed within the first branch, the second branch, and their common trunk (21%, 9.2%, and 22%, respectively). The lowest rate of the LACN fibers was found within the SBRN trunk (6.9%). ConclusionThe SBRN contains LACN fibers in almost 2/3 of the cases, therefore, the denervation of both nerves might be required to treat the neuroma. However, the method must be considered based on the particular clinical situation.

More potential uses of specific perforator flaps in the calf – A cadaveric study on the subdermal vascular structure of the lower leg

BackgroundThe perforator flap has garnered significant interest since its inception due to its advantage of not needing a vascular network at the deep fascial level. Perforator flaps are commonly utilized in different flap transplant surgeries, and the thigh flap is presently the most widely used perforator flap. Is it possible for the calf to replace the thigh as a more suitable site for harvesting materials? Currently, there is a lack of relevant anatomical research. This study aims to address this question from an anatomical and imaging perspective. MethodsThis study used cadavers to observe the branches and courses of perforators on the calf and the distribution of skin branches using microdissection techniques, digital X-ray photography, and micro-computed tomography techniques. ResultsThe perforators had three main branches: the vertical cutaneous branch, the oblique cutaneous branch, and the superficial fascial branch. The superficial fascial branch traveled in the superficial fascia and connected with the nearby perforators. The vertical and oblique cutaneous branches entered the subdermal layer and connected with each other to create the subdermal vascular network. ConclusionsWe observed an intact calf cutaneous branch chain between the cutaneous nerve and the perforator of the infrapopliteal main artery at the superficial vein site. Utilizing this anatomical structure, the calfskin branch has the potential to serve as a substitute for thigh skin flap transplantation and may be applied to perforator flap transplantation in more locations.

Lidocaine patch as noninvasive alternative treatment option in children with anterior cutaneous nerve entrapment syndrome: A retrospective case series.

Chronic abdominal pain in children is occasionally caused by anterior cutaneous nerve entrapment syndrome (ACNES). Diagnosing and treating this typical peripheral abdominal wall neuropathy is challenging. Management usually starts with minimally invasive tender point injections. Nevertheless, these injections can be burdensome and might even be refused by children or their parents. However, a surgical neurectomy is far more invasive. Treatment with a Lidocaine 5% medicated patch is successfully used in a variety of peripheral neuropathies. This single center retrospective case series aimed to evaluate the effectiveness and tolerability of lidocaine patches in children with ACNES. Children aged under 18 diagnosed with ACNES who were treated with a 10 day lidocaine patch treatment between December 2021 and December 2022 were studied. Patient record files were used to collect treatment outcomes including pain reduction based on NRS and complications. Twelve of sixteen children (mean age 13 years; F:M ratio 3:1) diagnosed with ACNES started the lidocaine patch treatment. Two patients achieved a pain free status and remained pain free during a 4 and 7 months follow-up. A third child reported a lasting pain reduction, but discontinued treatment due to a temporary local skin rash. Five additional patients reported pain reduction only during application of the patch. The remaining four children experienced no pain relief. No adverse effects were reported. Lidocaine patches provides pain relief in a substantial portion of children with ACNES.

Right-sided meralgia paresthetica from lateral femoral cutaneous nerveneuroma.

Meralgia Paresthetica (MP) causes outer thigh discomfort, numbness, and tingling. Compression or injury to the Lateral Femoral Cutaneous Nerve (LFCN), which gives sensory innervation to outer aspect of the thigh. It frequently gets impinged beneath the inguinal ligament resulting in in sensory impairment in the distribution of LFCN. Compression of the LFCN is a frequent cause of MP, whereas LFCN neuromas is a rare cause. This case report describes a unique case of Meralgia Paresthetica produced by a LFCN neuroma and enhances our knowledge of Meralgia Paresthetica.

Successful surgical excision of a melanoma and a rare peripheral nerve sheath tumor in 2 cattle

A heifer and a dairy cow were presented to our practice with cutaneous masses on the left side of their necks. Each mass had a diameter of approximately 20 cm. Both tumors had increased in size in recent weeks and were now prone to injuries from the stable equipment. Both animal owners agreed to surgical removal, which was performed under sedation and local anesthesia on a bovine treatment crush. The subsequent histopathological examinations of the extirpates revealed a melanocytoma in the young heifer and a cutaneous peripheral nerve sheath tumor (PNST) in the dairy cow. Both cases were benign tumors. The postoperative course was without complications and no recurrences were observed even more than a year later. No comparable tumors were found in related animals or in the offspring.

139 Alternative Anatomical Landmarks for the Lateral Femoral Cutaneous Nerve: Cadaveric Study With Implications for Difficult Decompressive Cases

INTRODUCTION: During decompressive procedures, localizing the lateral femoral cutaneous nerve (LFCN) using only the anterior superior iliac spine (ASIS) can be difficult due to variations in nerve course and specific patient anatomy, e.g., body habitus. Therefore, the present anatomical study was performed to provide additional landmarks for localizing this nerve. METHODS: The LFCN was dissected in 30 adult cadavers (60 sides). The nerve was exposed distal to the ASIS in the proximal thigh and along an imaginary line connecting the ASIS to the midpoint of the patella with the lower limb in a neutral position. RESULTS: The main trunk of the LFCN was identified deep to the fascia lata on all sides, 5-8 cm distal to the ASIS along the ASIS-patella line. The nerve was bordered by the sartorius muscle superficially and medially, the tensor fasciae latae muscle laterally, and the proximal rectus femoris tendon on its deep surface. Proximal to this triangular region, the LFCN was found to cross superficially to the proximal sartorius muscle on 58 sides and through the muscle on two sides. CONCLUSIONS: The study findings suggest an alternative method for identifying the LFCN, which could help locate the nerve during challenging cases and reduce the incidence of iatrogenic LFCN injuries resulting from inadequate anatomical landmarks.

Distal biceps tendon repair using a double intracortical button anatomic footprint repair technique

Distal biceps tendon repair is usually performed via a double-incision or single-incision bicortical drilling technique. However, these techniques are associated with specific complications and usually do not allow for anatomic footprint restoration. It was the aim of this study to report the clinical results of a double intracortical button anatomic footprint repair technique for distal biceps tendon tears. We hypothesized that this technique would result in supination strength comparable to the uninjured side with a low rerupture rate and minimal bony or neurologic complications. This was a retrospective, single-surgeon cohort study of a consecutive series of 22 patients with a mean (standard deviation) age of 50.7 (9.4) years and at least 1-year follow-up after distal biceps tendon repair. At final follow-up, complications, range of motion (ROM), the Patient-rated Elbow Evaluation (PREE), Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analog scale (VAS) for pain, patient satisfaction, and supination strength in neutral as well as 60° of supination were analyzed. Radiographic evaluation was performed on a computed tomography scan. One patient (4.5%) experienced slight paresthesia in the area of the lateral antebrachial cutaneous nerve. Heterotopic ossification was seen in 1 patient (4.5%). All patients recovered full ROM except for 1 who had 10° of loss of flexion and extension. Median PREE score was 4.6 (0-39.6), median MEP was 100 (70-100), and median DASH score was 1.4 (0-16.7). All but 1 patient were very satisfied with the outcome. The affected arm had a mean of 98% (±13%) of neutral supination strength (P=.633) and 94% (±12%) of supination strength in 60° (P=.054) compared with the contralateral, unaffected side. There were 4 cases (18.2%) of cortical thinning due to at least 1 button and 1 case of button pullout (4.5%). The double intracortical button anatomic footprint repair technique seems to provide reliable restoration of supination strength and excellent patient satisfaction while minimizing complications, particularly nerve damage and heterotopic ossification.

Periarticular cocktail injection is more useful than nerve blocks for pain management after anterior cruciate ligament reconstruction

BackgroundAnterior cruciate ligament (ACL) reconstruction is commonly associated with moderate-to-severe postoperative pain. Notably, various pain control strategies, a femoral nerve block (FNB) with a lateral femoral cutaneous nerve block (LFCNB), adductor canal block (ACB) with LFCNB, or periarticular cocktail injection (PI), have been investigated. However, no studies compare the effects of FNB with LFCNB, ACB with LFCNB, and PI for pain control after ACL reconstruction. This study aimed to evaluate the impact of FNB with LFCNB, ACB with LFCNB, and PI for pain relief in the early postoperative period after ACL reconstruction. MethodsThis retrospective controlled clinical trial enrolled 299 patients who underwent primary ACL reconstruction at our hospital between April 2016 and October 2022. We categorized these cases into groups based on the use of PI (PI group), FNB with LFCNB (FNB group), and ACB with LFCNB (ACB group) for pain management. We selected 40 cases each, with matched age, sex, and body mass index (BMI) from each group, resulting in 120 cases for analysis. In the FNB and ACB groups, 0.75% ropivacaine 15 ml was injected under ultrasound guidance preoperatively. In the PI group, a mixture of 0.75% ropivacaine 20 ml, normal saline 20 ml, and dexamethasone 6.6 mg was injected half at the start of surgery and the rest just before wound closure. Patient demographics (age, sex, height, body weight, and BMI) and surgical data (the requirement for meniscal repair, operative time, and tourniquet inflation time) were analyzed. After ACL reconstruction, patients' numerical rating scale pain scores (NRS) (0-10) were recorded at 30 min and 4, 8, 12, 24, 48, and 72 h postoperatively. NRS were then compared among the three groups using analysis of variance. In addition, within each group, these data were compared between the NRS ≥7 and NRS ≤6 groups using a t-test. ResultsThere were no significant differences in patient demographics and surgical data. Pain scores were significantly higher in the PI group than in the FCB and ACB groups 30 min postoperatively, but they were lower at 12, 24, 48, and 72 h postoperatively. In the FNB group, there were no significant differences in the demographic and surgical data by NRS pain score. In the ACB group, the number of men was significantly higher in the NRS ≥7 group than in the NRS ≤6 group (p = 0.015). In the PI group, tourniquet inflation time was significantly longer in the NRS ≥7 group than in the NRS ≤6 group (p = 0.008). ConclusionsFollowing ACL reconstruction using a hamstring autograft, periarticular cocktail significantly reduced early postoperative pain compared with nerve block combinations.

Anatomical Structures at Risk in Percutaneous Distal Bunionette Correction

Introduction/Purpose: Bunionette deformity affects 23% of the population and has numerous surgical options, including a minimally invasive approach (MIA) to decrease complications. Percutaneous surgery is favored by patients as it decreases pain, inflammation, and noticeable incision sites. Three possible osteotomy sites have been identified: proximal, diaphyseal, and distal. The study investigates the anatomic structures at risk during distal osteotomy of bunionette deformity using a Shannon burr. The distal osteotomy site was on average greater than 8mm from the extensor digitorum longus and adductor digiti minimi while it was 1.64mm from the lateral dorsal cutaneous nerve. The study highlighted the challenges posed by minimally invasive approaches to treating bunionette deformity and the need for cautious consideration when utilizing percutaneous methods. Methods: Eleven fresh frozen below-knee amputated foot and ankle cadavers were used for this study. Cadavers were allowed to thaw for 12 hours at room temperature before performing any tissue handling. All cadavers were visually inspected for evidence of gross pathology. Fluoroscopic radiographs were used to inspect for evidence of preexisting pathology of the fifth metatarsal. All cadavers with gross pathology or radiographic fifth metatarsal pathology were excluded from the study. All procedures were performed by a fellowship trained orthopaedic foot and ankle surgeon. Results: All eleven cadavers met the inclusion criteria for this study. The average age of the patients was 66.6 +/- 20.1 years. There were five female feet and six male feet. There were seven right feet and four left feet. Distance from the percutaneous access site was measured to structures at potential risk. The closest structure at risk was the lateral dorsal cutaneous nerve (LDCN) (1.64 mm), which was contacted 2/11 times and transected both times. The extensor digitorum longus (EDL) and abductor digiti minimi (ADM) had no instances of contact during the procedure. Dissection allowed for the identification of structures at risk and the assessment of osteotomy. All procedures resulted in a complete osteotomy. Conclusion: Overall, distal percutaneous bunionette osteotomy is largely safe. Structures pertinent to the surgery were identified with ease and were intact after osteotomy with a Shannon burr. Anatomic variations of LDCN can present challenges to the procedure. Meticulous dissection and judicious use of fluoroscopy can help prevent further damage. Surgeons should be aware of anatomic variations in order to proceed safely.