Preoperative Pain Levels Research Articles

Effect of Perioperative Gabapentin Use on Postsurgical Pain in Patients Undergoing Head and Neck Mucosal Surgery

Effective postoperative pain management increases patient satisfaction, reduces cost, reduces morbidity, and shortens hospitalizations. Previous studies investigating multimodal pain therapy in otolaryngology patients focused on homogenous patient groups with short postoperative follow-up times. To investigate the effect of perioperative gabapentin treatment on postsurgical pain in patients undergoing head and neck mucosal surgery. Adults undergoing head and neck mucosal surgery from July 25, 2016, through June 19, 2017, were included in this double-blinded, placebo-controlled randomized clinical trial and randomized to receive gabapentin, 300 mg twice daily, or placebo before surgery and up to 72 hours after surgery. Primary outcome was hourly narcotic use calculated in morphine equivalents. Secondary outcomes included subjective visual analog scale pain scores captured for resting, coughing, and swallowing using a 0- to 100-mm scale (a 100-mm line anchored with no pain on the left end and worst possible pain on the right end). A change of 10 mm or more was deemed to be clinically meaningful. Additional secondary outcome measures included degree of pain control, patient satisfaction, and adverse effects. Of the 110 patients randomized to receive gabapentin or placebo, 11 and 10 withdrew from each group, respectively. Ninety patients were then analyzed: 44 in the gabapentin group (mean [SD] age, 61.1 [10.0] years; 33 [75%] male; 40 [91%] white) and 46 in the placebo group (mean [SD] age, 60.9 [11.3] years; 35 [78%] male; 43 [94%] white). Both groups had similar self-reported levels of preoperative pain and narcotic effectiveness. A median difference of 0.26 mg/h of morphine (95% CI, -0.27 to 0.94 mg/h) was found between groups. After controlling for comorbidity and self-reported baseline pain levels, mixed model analysis found the difference in marginal means of visual analog scale scores between groups to be lower in the gabapentin group compared with the placebo group for all categories (rest difference, 7.9 mm; 95% CI, -0.4 to 16.2 mm; cough difference, 8.9 mm; 95% CI, -0.5 to 18.3 mm; swallow difference, 9.4 mm; 95% CI, -1.2 to 20.0 mm). More patients in the gabapentin group reported that pain was always well controlled than in the placebo group (difference, 9.2%; 95% CI, -21% to 3%). Gabapentin and placebo groups reported similar levels of satisfaction with pain control (difference, 2%; 95% CI, -11% to 15%). There was no clinically meaningful difference in reported nausea between the 2 groups (difference, 6%; 95% CI, -14% to 26%). Perioperative gabapentin given 300 mg twice daily did not result in reduced narcotic use, but results were compatible with clinically meaningful reductions in pain scores. Satisfaction with pain control and adverse effects were similar between groups. ClinicalTrials.gov Identifier: NCT02926573.

Effectiveness of Positron Emission Tomography/Computed Tomography as a Guide for Palliative Radiation Therapy for Spinal Metastases

As back pain is the presenting symptom in 95% of patients with epidural spinal metastases, appropriately identifying and treating the most symptomatic levels can provide significant palliation. The purpose of this study was to analyze the ability of combined positron emission tomography (PET)/computed tomography (CT) to identify spinal metastases with high metabolic activity and guide radiotherapy. We sought to correlate improvement in back pain with reduction in standard uptake value (SUV) after treatment. Retrospective review was performed of 72 patients with spinal metastases treated with stereotactic ablative radiation therapy at a single center between 2002 and 2014. PET/CT was used to calculate SUVs for spinal metastases, and treatment planning was based on PET/CT results. Preoperative and postoperative pain levels were assessed in all patients. Reduction in pain scores was found in 78% of treated patients. A significant reduction in pain was identified in patients with >5 metastases compared with fewer lesions (P < 0.05). Degree of change in SUV did not correlate significantly with pain relief. However, comparing pretreatment and posttreatment PET/CT, patients with improved pain consistently displayed decreased SUV. PET/CT was shown to be a useful adjunct in radiation treatment planning with change in SUV correlating with symptomatic improvement. This study paves the way for future prospective studies to further assess utility and cost-effectiveness of this imaging modality in radiation treatment planning for spinal metastases.

Anxiety and its predictive value for pain and regular analgesic intake after lumbar disc surgery - a prospective observational longitudinal study

BackgroundOngoing pain after surgery is a major problem and influences recovery and the quality of life of the patient. Associations between anxiety and their impact on postoperative pain after herniated disc surgery have been reported, but the results are inconsistent. The aim of the present longitudinal study was to evaluate the predictive value of preoperative anxiety for postoperative ongoing pain and prolonged analgesic intake after herniated disc surgery.Methods106 patients with lumbar disc herniation were evaluated in the study. Anxiety was measured with the Generalized Anxiety Disorder 7-Item Scale (GAD-7) before surgery. Pain intensity was assessed on a numeric rating scale (NRS) at baseline, 6-weeks and 6-months after surgery. Regression analysis was performed to identify independent predictors of pain and regular utilization of analgesics up to 6 months after surgery while controlling for confounding variables.Results42.5% of the patients were rated as anxiety cases (sum scores GAD-7 > 5), mean scores of anxiety showed mild to moderate symptom severity, and 43% suffered from chronic pain before surgery. Six months after surgery, 55.6% of the patients indicated pain levels of 4/10 (NRS) or higher and about 40% still took pain medication on a regular basis, regardless of their preoperative classification as anxiety-case (37.7% and 41.5%). The preoperative pain level was statistically significant for ongoing postsurgical pain in all four analyses (p < 0.001). With binary logistic regression analyses, preoperative pain intensity, but neither demographic factors nor preoperative anxiety, was identified as predictor for postoperative pain and need for analgesic medication up to 6 months after lumbar disc surgery.ConclusionWe found no evidence for the presence of anxiety before disc surgery being a prognostic factor for ongoing pain and regular postoperative intake of analgesics. Only preoperative pain intensity was predictive for increased pain and continued need for analgesic medication up to 6 months after lumbar disc surgery.Trial registrationClinicaltrials.gov NCT01488617. Registered 6 December 2011.

Effects of Various Cryotherapy Applications on Postoperative Pain in Molar Teeth with Symptomatic Apical Periodontitis: A Preliminary Randomized Prospective Clinical Trial

IntroductionThe purpose of the study was to evaluate the effects of intracanal, intraoral, and extraoral cryotherapy on postoperative pain in molar teeth with symptomatic apical periodontitis. MethodsA total of 100 patients were randomly distributed into 4 groups: control (without cryotherapy application), intracanal cryotherapy application, intraoral cryotherapy application, and extraoral cryotherapy application. The postoperative pain of the patients was recorded at the first, third, fifth, and seventh days. The data were statistically analyzed by using linear regression, χ2, one-way analysis of variance, Tukey post hoc, and Kruskal-Wallis H tests (P = .05). ResultsThere were no statistically significant differences among the groups in terms of demographic data (P > .05). The preoperative pain levels and preoperative visual analogue scale (VAS) scores of pain on percussion were similar among the groups (P > .05). The linear regression analysis demonstrated that group variable had the most significant effect on postoperative pain at day 1 (P < .001) among the other variables (group, age, gender, tooth number, preoperative pain levels, and VAS scores of pain on percussion). When compared with the control group, all the cryotherapy groups exhibited less percussion pain and less postoperative pain at the first, third, fifth, and seventh days (P < .05). ConclusionsWithin the study limitations, all the cryotherapy applications (intracanal, intraoral, and extraoral) resulted in lower postoperative pain levels and lower VAS scores of pain on percussion versus those of the control group.

Predicting intraoperative pain in emergency endodontic patients: clinical study.

This prospective observational study sought to investigate the incidence of intraoperative pain (IOP) among emergency endodontic patients and to construct an IOP prediction model that includes preoperative pain level (PPL). All patients who underwent emergency endodontic treatment at Gazi University, Ankara, Turkey, during the spring term of 2016 were considered for inclusion in the study. Demographic and clinical variables and PPL were recorded. Local anesthesia was provided to all patients before beginning routine endodontic treatment. IOP was defined as the condition of requiring supplementary anesthesia before the working length was established and exhibiting persistent moderate or severe pain despite supplementary anesthesia. Data from 85% and 15% of 435 patients (178 men, 257 women; mean age: 35 years) were used to develop predictive models by multiple logistic regression analysis and to test external validity of the models, respectively. Two multiple logistic regression models achieved good model fits. Model 1 included age, pulpal diagnosis, and arc (p < 0.05). In addition to these variables, Model 2 included periapical diagnosis and PPL (p < 0.15). Models 1 and 2 showed accuracies of 0.76 and 0.75, sensitivities of 0.74 and 0.77, and specificities of 0.76 and 0.74, respectively for the modeling data (internal validity), and accuracies of 0.82 and 0.80, sensitivities of 0.83 and 0.67, and specificities of 0.81 and 0.81, respectively for the control data (external validity). The IOP incidence was 10.3%. IOP in patients undergoing emergency endodontic treatment can be successfully predicted by using models that account for demographic and clinical variables, including PPL.

Symptomatic relief in medial opening wedge high tibial osteotomies for the treatment of knee osteoarthritis is influenced by concurrent procedures and preoperative pain level

ObjectivesMedial compartment osteoarthritis (OA) in the younger patient is technically challenging to treat. Medial opening wedge high tibial osteotomy (MOWHTO) is an option for surgical treatment; however, there remains a lack of evidence to establish the procedure as the preferred treatment option. The literature remains inconsistent with regard to patient characteristics and surgical factors that determine patient outcomes, particularly with respect to procedure survival and pain relief. The purpose of this study is to (i) describe the patient demographics and surgical outcomes of a consecutive series of MOWHTOs for treatment of medial knee OA; (ii) determine the procedure survivorship up to 10 years postsurgery and (iii) identify patient and surgery-related factors associated with pain relief following MOWHTO.MethodsA cohort of 210 patients was identified that underwent MOWHTO between 2002 and 2013. Patient demographics and complications were extracted from the clinical research database. Procedure survival analysis was conducted using a Kaplan-Meier analysis. All patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire preoperatively and postoperatively with pain relief identified as the difference between pre- and postoperative KOOS-pain subscale. A partial least square regression model was fitted to identify predictors of pain relief.ResultsMales comprised 84% of the cohort, which had a median age of 51 years (95% CI 42 to 57 years). Patients were overweight on average, with a median BMI of 28.9 kg/m2 (95% CI 23 to 36 kg/m2) and 36% of patients underwent concomitant procedures. A complication rate of 3.8% was observed. Survivorship was 97.7% at 5 years and 80% at 10 years, with median time to conversion in those requiring total knee replacement of 7 years (95% CI 5 to 8). Patients undergoing cartilage treatment and bilateral procedures experienced increased pain relief compared with average, while there was reduced pain relief in patients with lower preoperative pain.ConclusionMOWHTO is an effective procedure for relief of pain associated with medial knee OA, even in older and heavier patients. Patients and clinicians can expect an average procedure survival of 12.5 years and a maximum of 21 years, with effective pain relief influence by cartilage treatment and preoperative pain score.Level of evidenceIV. Case series.

Analgesic Drug Prescription After Carpal Tunnel Surgery

Carpal tunnel syndrome is a frequent cause of neuropathic pain of the upper limb. Surgery is often proposed in second-line treatment, leading to an expected decrease in analgesic drug consumption. The main objective of this study was to investigate the variations in analgesic drug prescriptions, with a special focus on constant or increasing prescription patterns, before and after surgery for carpal tunnel syndrome. We designed a retrospective cohort study of French beneficiaries from the health insurance system in Midi-Pyrénées area. All patients undergoing carpel tunnel surgery during a specified period were identified and included. Definition of increased or constant prescription of analgesics was based on the comparison of the accumulated defined daily doses received by months and a difference between early preoperative (2 months before) and late postoperative period (2-12 months after surgery) superior to a -3.5 margin. We performed 4 multivariate logistic regression models to identify factors associated with increased or constant analgesic drug prescription patterns (for all analgesics, opioid, antineuropathic, nonopioid drugs). Among the 3665 patients included, 3255 (89%) received at least 1 analgesic drug during the late postoperative period (39% [n = 1426] for opioids and 15% [n = 563] for antineuropathic drugs). Prescription of analgesic, opioid, or antineuropathic drugs was maintained or increased in the late postoperative period in 11%, 5%, and 3% of the population, respectively. High levels of preoperative pain and female sex were associated with an increase in opioid use, whereas inpatient surgery (vs ambulatory surgery), high levels of preoperative pain, and psychiatric disorders were found to be associated with an increase in antineuropathic drug use. This study revealed that approximately 3% to 5% of patients undergoing carpal tunnel surgery had persistent and even increased use of opioid or antineuropathic drugs more than 2 months after surgery, in relation with possible chronic postoperative pain. Considering the incidence of carpal tunnel syndrome, the risks associated with persistent opioid use in this population should be further monitored.

Effectiveness of Single-Port Thoracoscopic Splanchnicectomy in Controlling Pain in Patients with Chronic Pancreatitis

Introduction: Chronic pancreatitis is defined as a persistent pancreatic inflammatory disease. In chronic pancreatitis, recurrent episodes of inflammation lead to the replacement of pancreatic parenchyma with fibrotic connective tissue. Chronic pancreatitis pain, which may initially mimic acute pancreatitis, is severe, frequent, and continual and has a major impact on the quality of life and social functioning of patients. The standard treatments for this disease are endoscopy, surgery, splanchnic nerve denervation, thoracoscopic splanchnicectomy (TS), and video-assisted thoracoscopic surgery (VATS). Considering the advantages of the single-port method, we attempted to describe the post-treatment conditions of the patients undergoing this therapeutic approach.Materials & Methods: Ten chronic pancreatitis patients with severe resistant pain volunteered to enter the study. We recorded the data on patients’ age, gender, pre-operative pain level, surgical complications, and post-operative pain level (two weeks after surgery) were recorded. Visual analogue scale (VATS) was used for pain assessment and paired sample t-test was performed for statistical evaluation of response to the treatment for pain.Results: The participants included one female and nine male patients with the mean age of 53.3±0.8 years. The mean duration of severe pain before the onset of treatment was 13 months (range: 6 to 20 months). The pain level was determined 3 to 5 days before the operation and re-graded two weeks post-operation. Pre- and post-operative pain scores showed a significant reduction in the severity of pain before and after surgery (P<0.004).Conclusion: Single-port technique is recommended as a safe way to reduce pain in patients with chronic pancreatitis.

Low-level laser therapy may reduce postoperative pain levels after root canal retreatment in patients with low preoperative pain levels

Low-level laser therapy may reduce postoperative pain levels after root canal retreatment in patients with low preoperative pain levels

Is chronic postsurgical pain surgery-induced? A study of persistent postoperative pain following breast reconstruction

BackgroundChronic postsurgical pain (CPSP) is a reported risk for women undergoing breast reconstruction, but it remains unclear that such persistent pain is induced by reconstructive surgery. To address this concern, this prospective cohort study examined the prevalence of and risk factors associated with CPSP among women undergoing breast reconstruction. Materials and methodsWomen (n = 1996) recruited for the Mastectomy Reconstruction Outcomes Consortium (MROC) Study were assessed preoperatively and at two-years postoperatively for relevant medical/.surgical variables, pain experience, body physical well-being, anxiety, depression, and reconstruction procedure type and characteristics. ResultsNearly half of the entire sample reported some level of preoperative pain. At two years there were statistically significant but not clinically meaningful increases in both pain intensity and chest/upper body discomfort but a decrease in affective pain rating. Average clinical pain severity was strikingly similar for preoperative and postoperative assessments. Preoperative levels of pain, acute postoperative pain, and (marginally) level of depression held consistent relationship at two-year follow-up with all outcome measures. Autologous flap reconstruction was associated with more severe CPSP compared to TE/I reconstruction. Older age, higher BMI, bilateral reconstruction, and adjuvant radiation and chemotherapy were associated with CPSP and chest/upper body discomfort for at least one outcome measure at two years. ConclusionsThe substantial rate of preoperative pain and comparable prevalence of preoperative and postoperative pain ratings suggest that persistent pain after breast reconstruction may not necessarily reflect surgery-induced pain. Future research will need to determine those factors that contribute to long-term pain following breast reconstruction.

Associations between dental anxiety and postoperative pain following extraction of horizontally impacted wisdom teeth: A prospective observational study.

The aim of the study is to identify associations between dental anxiety and postoperative pain in patients undergoing extraction of horizontally impacted wisdom teeth.A total of 119 volunteers provided demographic data, and completed questionnaires, the State-Trait Anxiety Inventory (STAI), Chinese Index of Dental Anxiety and Fear (C-IDAF)-4C, and the Numeric Rating Scale (NRS) for pain.Mean SAI, TAI, and C-IDAF-4C scores were 42.5 ± 8.7, 46.4 ± 10.9, and 16.9 ± 7.2, respectively. Mean postoperative pain level score was 3.0 ± 1.8 (range: 0.3–8.4). SAI scores increased as preoperative pain levels increased (β = 1.30, 95% confidence interval [CI]: 0.62–1.98, P < .001); females had higher SAI scores than males (5.34; 95% CI: 1.74–8.95, P = .004). Multivariable analysis revealed that females, bad exodontic experience, and higher predicted pain levels were associated with higher IDAF-4C scores. SAI scores (γ = 0.611, P < .001) and TAI scores (γ = 0.305, P < .001) increased as C-IDAF-4C scores increased. Higher C-IDAF-4C scores and longer operative time were significantly associated with higher levels of postoperative pain.Specific factors are associated with anxiety and stress, and postoperative pain in patients undergoing wisdom teeth extraction. Addressing these factors preoperatively may reduce stress and anxiety, and lead to more favorable treatment outcomes.

The Influence of Patient Factors on the Outcome of Synthetic Cartilage Implant Hemiarthroplasty versus First Metatarsophalangeal Joint Arthrodesis

Category: Midfoot/Forefoot Introduction/Purpose: Many studies have compared the outcomes of MTPJ1 hemiarthroplasty and arthrodesis, but there is a paucity of data on the influence of patient factors on clinical outcomes. A prior prospective, randomized, clinical trial compared the efficacy and safety of first metatarsophalangeal joint (MTPJ1) hemiarthroplasty with a synthetic polyvinyl alcohol hydrogel implant (Cartiva®) and MTPJ1 arthrodesis for moderate to severe hallux rigidus. The current study evaluated the data from this clinical trial to determine the impact of numerous patient variables, including osteoarthritis grade, hallux valgus angle, preoperative range of motion (ROM), gender, body mass index (BMI), preoperative duration of symptoms, and preoperative pain level, on the success or failure of MTPJ1 hemiarthroplasty and arthrodesis. Methods: Patients =18 years diagnosed with hallux rigidus grade 2, 3, or 4 were randomized and treated with synthetic cartilage implant MTPJ1 hemiarthroplasty (n=129) or arthrodesis (n=47). Outcome measures included a pain visual analogue scale (VAS), Foot and Ankle Ability Measure (FAAM) Sports and Activities of Daily Living (ADL) scores, and Short Form-36 Physical Functioning (SF-36 PF) subscore, obtained preoperatively and at 2, 6, 12, 24, 52 and 104 weeks postoperatively. Great toe active dorsiflexion motion, secondary procedures, radiographs and safety parameters were evaluated. A patient’s outcome was deemed successful if composite primary endpoint criteria for clinical success (pain, function and safety) were met at 24 months. Predictor variables included: osteoarthritis grade; hallux valgus angle; preoperative ROM; gender; body mass index (BMI); preoperative symptom duration; prior surgery; and preoperative pain level. Two-sided Fisher’s Exact test was used to assess the impact of these variables on success of surgery (p&lt;0.05). Results: Standard patient demographics and baseline outcome measures were similar for both groups; both procedures demonstrated equivalent pain relief and functional outcomes.1 There was no significant difference (p&gt;0.05) in success rates (i.e., VAS pain reduction ≥ 30%, maintenance/improvement in function, freedom from radiographic complications, and no secondary surgical intervention) between synthetic cartilage implant MTPJ1 hemiarthroplasty and arthrodesis when stratified by osteoarthritis grade, degree of preoperative hallux valgus, extent of preoperative ROM, gender, BMI, duration of symptoms, prior MTPJ1 surgery status, and preoperative pain VAS score (Table 1). Notably, patients with minimal ROM and mild hallux valgus had equivalent success rates for both procedures. Males tended to have greater clinical success with implant hemiarthroplasty versus arthrodesis, but this difference was not statistically significant. 1Baumhauer et al., FAI, 2016;37(5):457-69. Conclusion: Synthetic cartilage implant hemiarthroplasty is an appropriate treatment for patients with hallux rigidus of Coughlin grade 2, 3 or 4. Its results in those with associated mild hallux valgus (&lt;20 degrees) and in those with a high degree of preoperative stiffness are equivalent to MTPJ1 fusion, irrespective of gender, BMI, osteoarthritis grade, or preoperative pain or duration of symptoms, in contrast to what might have been expected.

Lundborg's resection arthroplasty vs. Pyrocarbon spacer (Pyrocardan®) for the treatment of trapeziometacarpal joint osteoarthritis: a two-centre study

Background Various operative approaches exist for osteoarthritis of the trapeziometacarpal joint. The aim of this two-centre study was to compare the results of Lundsborg's resection arthroplasty with the implantation of the Pyrocardan® spacer. Patients and methods We treated 20 patients with symptomatic osteoarthritis of the trapeziometacarpal joint in stage III / IV (Eaton-Littler classification). Twelve patients received Lundsborg's resection arthroplasty (centre 1), and in 8 patients a Pyrocardan® spacer was implanted (centre 2). Both groups were comparable regarding patients´ age, the preoperative pain level, the osteoarthritis stage according to Eaton-Littler, and the duration from the onset of symptoms until surgery. Patient data were retrospectively collected from patient records, and we performed a follow-up examination at least 18 months postoperatively, thereby evaluating the DASH sore, the postoperative time until freedom of symptoms, the pain level according to the visual analogue scale, grip force (Jamar dynamometer), pinch force, and patients' treatment satisfaction (0-10; 10 = highest satisfaction). Results Both groups had a similar length of follow-up with 23.6 ± 5.2 months for the resection group and 26.1 ± 4.0 months for the spacer group. The duration of the operation was 31 ± 5 min for the resection group and 29 ± 7 min for the spacer group (p > 0.05). The DASH score was 21.9 ± 6.2 in the resection group and 18.3 ± 5.0 in the spacer group (p > 0.05). The pain level at the current follow-up was 1.5 ± 0.83 in the spacer group and 1.0 ± 0.74 in the resection group (p > 0.05). The time until freedom of symptoms was significantly shorter in the spacer group with 3.7 ± 1.9 months compared to the resection group with 5.7 ± 3.1 months (p = 0.0001). Grip force and pinch force were not significantly different between both groups. Treatment satisfaction was 9.3 ± 1.6 in the resection group and 7.4 ± 3.0 in the spacer group (p > 0.05). Conclusion Over a follow-up period of 1.5 years, both techniques resulted in a satisfactory usability of the operated hand and a clear reduction of symptoms. The implantation of the Pyrocardan® spacer seems to have slight advantages regarding a shorter time until freedom of symptoms. However, the implantation of the spacer is associated with additional material costs of a few hundred Euros, which are not incurred in resection arthroplasties. The implantation of the Pyrocardan® spacer seems to have slight advantages regarding a shorter time until freedom of symptoms.

Predictability of Postoperative Pain and Satisfaction. How Precise Are We and What Is the Role of Professional Experience?

Background The indication for surgery is justified by an expected improvement for the patient. To evaluate the probability and extent of individual postoperative patient benefit, the surgeon needs to elaborate numerous parameters of potential relevance for the outcome beyond his key competence, that is the technical dimension of the operation. Despite the highest medical standards, individual postoperative satisfaction with surgery is highly variable, even in cases with a technically good result. The aim of the present study was to investigate the individual predictability of postoperative pain and satisfaction in patients with elective musculoskeletal surgery. Moreover, it was analysed whether the quality of the prediction of the outcome depends on professional experience and if a better prediction can be obtained in such a highly standardised procedure as primary total arthroplasty. Patients/Material and Methods In our hospital on the day before surgery, patients with their medical history are presented to the head of department and a short clinical examination is performed as well as a joint analysis of radiographic images. During this grand round, doctors gave a written preoperative estimation of both expected postoperative satisfaction and pain at 6 months after surgery on a scale from 0 - 10. At 6 months postoperatively, patients were asked to give their actual level for these two parameters. Preoperative estimations were obtained from both senior and resident physicians and compared with the values actually reported by the patient. Results A total of 194 physicians' predictions of 63 patients were analysed. Preoperative pain levels were reduced markedly by surgery from a median NRS of 6.25 to 2.5 (p < 0.001). Median prediction for postoperative pain was 2 (IQR 2), which is only slightly more optimistic than reported. On an individual level, the discrepancy between prediction and actual outcome was, however, considerable - with a median absolute difference of 2 (IQR 3) values on the scale. This means that only 50% of all predictions were close enough to the actual value to be at least in the correct half of the entire scale. When looking at prediction precision as a function of professional experience, no difference could be observed between senior and junior doctors (p = 0.738 for postoperative pain and p = 0.370 for satisfaction with surgery). Even in primary arthroplasty patients (n = 17), precision of outcome prediction for pain was no better that in the remaining collective (p = 0.634). With respect to postoperative satisfaction, precision of prediction was even worse (p = 0.042), as satisfaction was slightly underestimated by the physicians in the primary arthroplasty group, by a median of 1. Conclusion While general prediction showed almost perfect agreement with actual postoperative values, individual predictability showed highly variable results. Even in such a standardised collective as primary arthroplasty, this scattering of deviation was observed. Since professional experience did not lead to improved results, it can be speculated that, beside the technical dimension of surgery, other factors such as patient expectation are of crucial relevance for postoperative outcome. To further improve outcome and patient satisfaction with surgery we therefore recommend developing an individualised and realistic prognosis together with each patient, but bearing in mind own limits of outcome prediction.

Intra-articular “Cocktail” Offers Clinical Advantages over Femoral Nerve Block for Postoperative Analgesia in Patients Undergoing Arthroscopic Hip Surgery

Objectives:Arthroscopic hip surgery has gained considerable popularity over the past several years. Attempts to optimize peri and postoperative pain control continues to represent a challenge and opportunity for clinical improvement. Multiple regional anesthesia strategies have been utilized by arthroscopic hip surgeons, including lumbar plexus and femoral nerve blockade, however these options can be associated with setbacks including technical difficulty, intravascular injection, increased post-operative fall risk and the development of peripheral neuritis. Therefore, exploration of alternative regional anesthesia strategies holds promise for improved clinical outcomes. This study aims to explore the efficacy and complication rate of intra-articular anesthetic administration in patients undergoing arthroscopic hip surgery.Methods:A retrospective analysis of prospectively collected data was conducted to identify all patients undergoing elective arthroscopic hip surgery between November 2013 and April 2015. Subjects were stratified into either a group that had received a preoperative femoral nerve block for perioperative pain control or a group that had an intra-articular injection of local anesthetic administered by the surgical team intraoperatively. Objective data, including pre and post-op pain scores in the PACU, total dose of narcotics required perioperatively, occurrence of falls and development of peripheral neuropathy were collected for analysis. Data was compared between the two groups using linear and logistic regression modeling. Statistical significance was determined as p<0.05.Results:After excluding patients who did not meet the criteria for study participation, a total of 193 patients were included in this study. At the time of surgery, one hundred eighty three patients (95%) demonstrated evidence of labralchondral pathology and bony morphology characteristic of femoroacetabular impingement (FAI). One hundred five patients (54%) received a pre-operative femoral nerve block and 88 patients (46%) received an intra-operative intra-articular injection of anesthetic agents. Linear models for post-operative pain, controlled for patient age and pre-operative pain levels, revealed that patients receiving pre-operative femoral nerve blocks had significantly less pain at discharge (p<0.05). There was no statistically significant difference in pain scores between patients receiving pre-operative femoral nerve blocks and those receiving intra-articular injections at post-operative weeks 1, 3 and 6. Patients receiving pre-operative femoral nerve blocks were found to be 3.6 times more likely to experience a post-operative fall (OR 3.58, p < 0.05) and were 14 times more likely to experience post-operative neuropathy (OR 13.99, p < 0.01) than patients receiving an intra-articular injection.Conclusion:Intra-articular anesthetic administration was found to be similar in efficacy to pre-operative femoral nerve blocks at reducing post-operative pain in patients undergoing hip arthroscopy. Additionally, patients receiving intra-articular injections had a significantly decreased risk of falling post-operatively or developing peripheral neuritis, known complications of femoral nerve blocks. With this information, intra-articular anesthetic administration appears to be a safe alternative to femoral nerve blocks in patients undergoing hip arthroscopy.Table 1 Demographic Data Group 1: FemBlock (n=105)Group 2: IABlock (n=88)P valueSex, n Male38270.42 Female6761 Age, mean ± SD, y33.4 ± 13.0231.3 ± 14.050.29Smoking history, n 0.66 Yes2826 No7762 Workers Compensation, n 0.24 Yes41 No10167 History of Chronic Pain, n 0.35 Yes46 No10182 Table 2 Outcomes Group 1: FemBlock (n=105)Group 2: IA Block(n=88)P ValuePreoperative Preoperative pain, mean ± SD3.54 ± 2.693.69 ± 2.430.69Intraoperative Total Dose of Dilaudid, mean ± SD, mg0.18 ± 0.330.22 ± 0.370.40Postoperative Pain on PACU Arrival4.59 ± 2.856.16 ± 2.56<0.01* Pain at Discharge3.55 ± 2.264.28 ± 3.130.03* Pain at 1 week3.05 ± 2.182.75 ± 2.160.34 Pain at 3 weeks1.96 ± 2.131.82 ± 2.070.64 Pain at 6 weeks1.70 ± 2.091.59 ± 1.950.7 Reported a fall, n195<0.01* Developed Peripheral Neuritis, n262<0.01*

Identification of pre-operative of risk factors associated with persistent post-operative pain by self-reporting tools in lower limb amputee patients – A feasibility study

Abstract Aims The incidence of persistent post-operative pain (PPP) is 30–85% in lower limb amputee (LLA) patients and identification of preoperative risk factors are warranted. Preoperative levels of anxiety, depression, pain catastrophizing, neuropathic pain and severe preoperative pain have previously been linked with PPP but such screening tools are not used in the clinical hospital setting. The aim of this study was to assess feasibility of using questionnaires for anxiety, depression, pain catastrophizing, neuropathic pain and preoperative pain levels in a clinical preoperative setting. Methods Patients scheduled for non-traumatic amputation of the lower leg or femur were recruited from three Danish hospitals. Exclusion criteria were surgery 4-weeks prior to LLA, same leg re-amputation, or inability to participate. Pre-operative values of anxiety, depression and catastrophizing were assessed using the Hospital Anxiety (A) and Depression(D) Scale (HADS) (cutoff: 8) and Pain Catastrophizing Scale (PCS) (cutoff =32). Neuropathic pain was assessed preoperatively using Pain-Detect-Questionnaire (PD-Q) (cutoff: 19). The maximum preoperative pain intensity was assessed using the Numeric Rating Scale (NRS; 0: no pain and 10: worst imaginable pain). Scores are presented as median values with interquartile range (Q1–Q3). Results Eight of 18 patients (5 females) completed this pilot study: median age 71 (range 56–83), 6 femur and two lower leg amputees. Nine of ten excluded patients were unable to complete the questionnaires and one patient was operated acutely. Median pre-operative HADS-D and -A scores were 7 (3–9, 50% ≥ cutoff) and 4 (1–8, 25% ≥ cutoff), pre-operative PCS score was 24 (18–28, 13% ≥ cutoff), pre-operative PD-Q score was 16 (8–22, 50% ≥ cutoff) and NRS score was 9.5 (8–10). Conclusions This study indicates that it is possible to implement preoperative questionnaires in a clinical setting. However, more than 50% of the patients are unable to complete the questionnaires.

The Maryland Orthopaedic Registry (MOR): Design and baseline characteristics of a prospective registry.

Utilization of patient-reported outcome tools allows a more accurate assessment of the efficacy of treatment, which is critical to comparative effectiveness research. The Maryland Orthopaedic Registry (MOR) was established to assess post-surgical outcomes related to patients' pain, functional status, met expectations, and satisfaction using an electronic data collection system. Secondary aims of the registry include assessment of patient expectations of treatment, activity level, and general health status. Adult patients enrolled in this prospective observational study completed self-report measures assessing pre-operative pain, function, treatment expectations, and activity levels during the perioperative period. MOR utilizes the Patient-Reported Outcomes Measurement Information System (PROMIS®)'computer adaptive testing for physical function, pain interference, fatigue, social satisfaction, anxiety, and depression. Perioperative data is extracted from the medical record. 300 patients (40% of eligible) have been enrolled into the initial cohort. Most patients (94.1%) were aged 18-65, and 57% were male. Fifty-seven percent of enrollees were White, 33% Black, and 4% Asian. PROMIS physical function and social satisfaction were both more than half a standard deviation below the population mean. Participants reported PROMIS anxiety scores that were half a standard deviation above the population mean and pain interference scores that were more than a standard deviation above the mean. Physical function scores were significantly worse among participants with lower extremity orthopaedic issues, but scores on other measures were similar between participants undergoing lower or upper extremity surgery. MOR provides a comprehensive assessment of patients undergoing orthopaedic surgery. The utilization of electronic clinical assessment tools as well as computer adaptive testing allows for time-efficient data collection. The diverse population is a particular strength of MOR.

WHAT INFLUENCE ON EARLY POSTOPERATIVE PAIN INTENSITY AFTER TOTAL KNEE ARTHROPLASTY?

Purpose – to describe the relationship of selected socio-demographic, clinical, and surgical factors with the severity and patterns of postoperative pain during the first three days following total knee arthroplasty.Material and methods. The sample included 100 patients (93 women and 7 men; mean age 63.5±7.8 years) with osteoarthritis admitted for primary total knee arthroplasty. Prior to surgery, standard measures were used to assess preoperative pain and other symptoms, clinical manifestations of osteoarthritis, functional status of the knee, comorbidities, functional abilities, quality of life, and other patient characteristics. Physical, biochemical and surgical parameters of the perioperative period were also recorded. Patterns of daily changes in postoperative pain characteristics were investigated with the use of individual diaries. Results. All the analyzed indicators of postoperative pain progressively decreased during the three days after surgery (р0,001), including the number of daily hours of moderate to severe pain (р0,001). Pain levels were generally higher among women than among men (р = 0,009). Of the analyzed preoperative factors, higher levels postoperative pain were correlated with higher levels of anxiety (р = 0,029) and preoperative pain intensity (р = 0,029). Among the perioperative factors, surgery duration longer than 90 minutes was associated with higher levels of postoperative pain in activity (р = 0,012) and more hours of moderate/severe pain (р = 0,008). Characteristics of postoperative pain were unrelated to level of patient education, social or family status, employment, lifestyle, or any other clinical or laboratory variables.Conclusion. Of the many factors previously associated with postoperative pain, only gender, anxiety and level of preoperative pain confirmed their importance in this study. Among the perioperative factors, surgery duration, which varied by the type of implant, was significantly associated with postoperative pain levels.

Important patient characteristics differ prior to total knee arthroplasty and total hip arthroplasty between Switzerland and the United States

BackgroundOutcomes after total knee (TKA) and hip (THA) arthroplasty are often generalized internationally. Patient-dependent factors and preoperative symptom levels may differ across countries. We compared preoperative patient and clinical characteristics from two large cohorts, one in Switzerland, the other in the US.MethodsPatient characteristics were collected prospectively on all elective primary TKAs and THAs performed at a large Swiss hospital and in a US national sample. Data included age, sex, education level, BMI, diagnosis, medical co-morbidities, PROMs (WOMAC pain/function), global health (SF-12).ResultsSix thousand six hundred eighty primary TKAs (US) and 823 TKAs (Swiss) were evaluated. US vs. Switzerland TKA patients were younger (mean age 67 vs. 72 years.), more obese (BMI ≥30 55% vs. 43%), had higher levels of education, more cardiac disease. Swiss patients had lower preoperative WOMAC pain scores (41 vs. 52) but pre-operative physical disability were comparable. 4,647 primary THAs (US) and 1,023 THAs (Swiss) were evaluated. US vs. Switzerland patients were younger (65 vs. 68 years.), more obese (BMI ≥30: 38% vs. 24%), had higher levels of education, more diabetes. Swiss patients had lower preoperative WOMAC pain scores (40 vs. 48 points). Physical disability was reported comparable, but Swiss patients indicated lower mental health scores.ConclusionWe found substantial differences between US and Swiss cohorts in pre-operative patient characteristics and pain levels, which has potentially important implications for cross-cultural comparison of TKA/THA outcomes. Reports from national registries lack detailed patient information while these data suggest the need for adequate risk adjustment of patient factors.

Treatment Outcome of Hip Arthrosis by a Mini-Open Direct Anterior Approach (DAA) in Patients with American Society of Anaestesiology Scale III (ASA III)

Introduction: Osteoarthrosis (OA), often followed by femoroacetabular impingement (FAI) is a recognized condition that purportedly contributes to full degenerative changes of the hip (OA). The standard procedure for advanced degenerative joint disease is total hip replacement. This is a procedure with an increased risk of cardiovascular events for the patients. The risk of deep vein thrombosis (DVT), fat embolism, cardiological abnormalities in the course of the procedure and the consequences of interference in the pelvic girdle and the femoral cavity of the femur, significantly increases [1,2]. Because of the above risks in patients with ASA III, it was decided to use a less invasive procedure in bone and muscle tissue without interfering into the spongy bone of the femur and the bone acetabulum. We used minimally invasive direct anterior approach (MIS DAA) to remove massive bone osteophosphites, discard the joint and improve the range of the joint motion (Range of Motion, ROM). The aim of the present study was to describe the outcomes of the miniopen DAA in treating patients with arthorosis and FAI and compare them to the reported outcomes of other approaches. Materials and methods: This is a retrospective review of 21 patients (17 males, 4 females, mean age 51.4 [range 43 to 55] years) who were treated for OA by the miniopen DAA. The mean follow-up was 35 months (range 21 to 51).Preoperative osteoarthritis was assessed according to the Tonnis score. Preoperative and postoperative pain levels were assessed by a 10-point visual analog scale (VAS) score. The functional outcomes of hip joint were evaluated by the Short-Form 36 Health Survey (SF-36) and the Harris Hip Score (HHS). Results: There was a significant improvement in the HHS score (p<0.00001), the VAS score (p<0.001) and the SF-36 score (p<0.001) at the final follow-up compared to the preoperative status of our patients. Fifteen of patients returned to their previous activities. No major cardiac complications occurred. All patients were done with spinal anesthesia. One patient developed heterotopic ossification after 6 month post op and two other patients had temporary postoperative meralgia paresthetica. Two patients were referred to total hip arthroplasty due to severe osteoarthritis after 2 years post MIS DAA treating. Conclusions: The MIS DDA (minimal invasive anterior hip approach) is a safe and effective procedure for patients with OA and cardiac disease (ASA III) and may be considered as an alternative to primary total hip replacement for the treatment of early and middle AO and FAI. Further research in a larger cohort of AO and ASA II, III and IV patients with a longer follow-up period is recommended.