Mean Pain Level Research Articles

Excellent results and low complication rate for anatomic polyaxial locking plates in comminuted proximal ulna fractures

Comminuted fractures of the proximal ulna remain a great challenge in orthopedic surgery. The purpose of this study was to report the outcomes of comminuted proximal ulna fractures treated with a new construct type-anatomically preformed polyaxial locking compression plates. Between 2013 and 2016, 46 patients with isolated comminuted fractures were treated with a 2.7-/3.5-mm VA-LCP Olecranon Plate (Synthes, Umkirch, Germany). Of these, 44 were available for an assessment after a mean follow-up period of 2.5 years (range, 12-50 months). We evaluated range of motion, time to recovery, revision rate, and indications, as well as functional scores. Radiographs were analyzed. The study included 8 Mayo IB, 29 Mayo IIB, and 7 Mayo IIIB fractures. All fractures showed bony union, and only 2 revision surgical procedures were performed because of a new trauma. No other complications occurred. Mean range of motion was 139° (range, 105°-150°), and the mean pain level was less than 1 on a visual analog scale. Regarding elbow function, we found a mean Mayo Elbow Performance Score of 98; a mean Oxford Elbow Score of 44; and a mean Disabilities of the Arm, Shoulder and Hand score of 6. Of the plates, 41% were removed after an average time of 16 months, whereby a significant improvement in extension deficit was detected (P < .01). Ninety-five percent of all patients returned to their pretrauma sports level. The 2.7-/3.5-mm VA-LCP Olecranon Plate represents an effective option with excellent fracture reduction, sufficient stability for early postoperative functional rehabilitation, and a minimum of complications.

Pain in Maintenance Hemodialysis Patients: A Multicenter Study

ContextPain is a common complaint in maintenance hemodialysis (MHD) patients yet is often inadequately assessed and undertreated. ObjectivesThe objective of this study was to evaluate the prevalence, characteristics, intensity, and impact of pain in MHD patients. MethodsIn a cross-sectional study conducted between 2013 and 2015, 336 MHD patients from five hemodialysis units in hospitals owned by Clalit were interviewed and evaluated. Study tools included the Brief Pain Inventory, The Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale, and demographic and clinical characteristics. In addition, computerized pharmaceutical data were reviewed. ResultsPain was experienced by 82% of the study population (mean pain level: 7.2 ± 2.2) in the 24-hour period before the interview, while 61.5% experienced neuropathic pain characteristics. Of patients with pain, two-thirds reported being regularly treated with pain medications, while 24.5% received nondrug pain treatment. Mean pain relief due to Brief Pain Inventory was 62.5 ± 30%. In multivariate analysis, female gender, a high comorbidity index, and time on dialysis >24 months were associated with the presence of significant pain in the previous 24 hours. In addition, severe pain report was associated with female gender, depression, ≥4 painful sites, and unemployment. Finally, neuropathic pain was associated with time on dialysis >24 months, depression, ≥4 painful sites, and current intensity of pain >2. ConclusionPain is common in MHD patients and is significantly associated with female gender, comorbidity, time on dialysis, and depression. Results of this study may serve as a starting point for palliative interventions for MHD patients.

The Effectiveness of Standing on a Balance Board for Increasing Energy Expenditure while Performing Sedentary Work

It is estimated that occupational energy expenditure has decreased by 100 kcal·d-1. Analogous to sitting, too much standing that is static with little movement poses health risks. Innovative technologies such as balance boards have been developed for use within an office setting to replace sitting and encourage movement while standing, yet little is known whether physiological benefits exist or if productivity is affected. PURPOSE: To investigate differences in energy expenditure (EE), heart rate (HR), productivity, fatigue, and pain while performing desk work while sitting (SIT), standing (STAND), and standing on a balance board (BOARD). METHODS: Thirty healthy adults (60% female; age 39.7 ± 11.8 y; BMI 26.7 ± 5.0 kg·m-2) employed in sedentary-based jobs volunteered for this randomized crossover trial. Participants performed typing work in three different positions: SIT, STAND, and BOARD; each condition lasting 30 min. Oxygen consumption (VO2) was measured via indirect calorimetry and EE was calculated using respiratory quotient and corresponding caloric equivalent values. Productivity was quantified by measuring words typed per min, accuracy, and typing mistakes. Overall feelings of fatigue and pain were self-reported three times during each position using validated 10-cm visual analog scales. Repeated measures ANOVA were used to assess differences in outcome variables across conditions. RESULTS: VO was significantly different among all conditions regardless of current standing desk use (SIT 3.35 ± 0.53; STAND 3.77 ± 0.48; BOARD 3.92 ± 0.54 mL·kg- 1·min-1, p<0.001). EE (kcal·min-1) also differed (p<0.001) among SIT (1.27 ± 0.22), STAND (1.42 ± 0.26) and BOARD (1.48 ± 0.29). Compared to sitting (67 ± 9 bpm), HR was higher in STAND (76 ± 11 bpm) and BOARD (76 ± 11 bpm, p<0.001). Measures of productivity were similar across conditions (p>0.05). Mean self-reported fatigue and pain levels were similar across conditions (p>0.05). Fatigue progressively increased over each 30 min condition (p<0.001) whereas pain in SIT and BOARD increased from min 10 to 20, then leveled off between min 20 to 30. For STAND, pain continued to increase over time. CONCLUSION: Compared with sitting, a balance board may be effective for increasing EE without interfering with productivity in an occupational setting.

Prevalence and Risk Factors of Neuropathic Pain in Patients with a Rotator Cuff Tear

Until now, few studies had investigated the neuropathic pain component in patients with a rotator cuff tear (RCT). The aim of the study was to identify the neuropathic pain component in patients with RCT and to determine the factors correlated with neuropathic pain in patients with RCT. Prospective, cohort, prognostic study. Study patients who required arthroscopic rotator cuff repair were analyzed in a hospital setting. We prospectively studied 101 patients who were less than 60 years old with full-thickness tears requiring arthroscopic rotator cuff repair and met the inclusion and exclusion criteria. Multiple regression analysis was performed to identify variables that independently affected neuropathic pain in patients with a RCT. We use Douleur neuropathique 4 questionnaire (DN4) to assess neuropathic pain, which was >/= 4 points of the DN4 questionaire. The visual analog scale (VAS) for the most severe pain within 4 weeks before admission and mean pain level during the last 4 weeks were checked. The atrophy grades of the rotator cuff muscles were classified on magnetic resonance images according to the Goutallier classification. The size and medial retraction of the RCT were measured during arthroscopic repair for RCT. Sixteen (15.8%) of the 101 patients had neuropathic pain according to the cut-off values on the DN4 questionnaire for diagnosing neuropathic pain. The neuropathic pain group had significantly higher prevalence of smoking (P = 0.042), more mean VAS during last 4 weeks (P = 0.008), larger cuff tear (P = 0.003), more medial retraction of cuff (P = 0.016), and severe fatty degeneration of rotator cuff muscles (supraspinatus, P < 0.001; subscapularis, P < 0.001; and infraspinatus, P = 0.003) than the nonneuropathic pain group. The multiple logistic regression analyses showed that more mean VAS during the last 4 weeks and tear size of a rotator cuff were independent of other factors for the neuropathic pain of the patients with a full-thickness RCT. Small sample size is the first limitation of this study. The prevalence of neuropathic pain in patients with a full-thickness RCT requiring arthroscopic rotator cuff repair was 15.8 % according to the DN4 questionnaire. The neuropathic pain component was more relevant to the severity of pain and tear size in the patients with a full-thickness RCT. It is important to be aware of the existence of neuropathic pain when treating a patient presenting with pain due to a RCT because accompanying neuropathy with a RCT could have a worse effect on repair of a RCT. IRB approval and clinical trial registration number: CR-15-045. Shoulder, rotator cuff tear, arthroscopic rotator cuff repair, neuropathic pain.

The Long Term Effectiveness of Genicular Nerve Blocks for Chronic Knee Pain: A Retrospective Study

Chronic knee pain is a leading cause of chronic disability and its symptoms have a profound impact on the lives of those suffering from it. Current treatment modalities for chronic knee pain include pharmacologic and nonpharmacologic interventions. Genicular nerve blocks are a new therapeutic alternative that have been shown to relieve chronic knee pain and may provide significant relief in patients who are either poor surgical candidates or are unwilling to accept the risks associated with surgery. Genicular nerve blocks may provide long term pain relief for chronic knee pain and radiofrequency ablation (RFA) may not be necessary. This Institutional Review Board (IRB) approved retrospective study conducted at a single center university hospital involved 44 patients aged 43 to 87 who received genicular nerve blocks for chronic knee pain. The primary purpose of this study was to determine if genicular nerve blocks provide effective long term pain relief for patients with chronic knee pain. The numeric rating scale was used to measure the patient’s knee pain at baseline, 30, 90, and 120 days post procedure. Patients experienced a mean pain level of 7.43 out of 10 before the genicular nerve block and 4.02 afterward representing an average improvement of 42.6% in pain relief overall post procedure follow-up. A t-test revealed a statistically significant difference between the mean pain score before and after the blocks (t = 8.534, P &lt; 0.01). Overall, the patients experienced significant pain relief of an average of 111.9 days resulting in an average of 42.6 percent pain relief post procedure follow-up. Out of the 44 patients, 15 (34.1%) underwent a RFA after receiving a genicular nerve block procedure to further manage their chronic knee pain symptoms. In conclusion, we have found statistically significant evidence that genicular nerve blocks provide effective long-term pain relief for patients with chronic knee pain. Therefore, for patients who are not surgical candidates, genicular nerve blocks represent a viable alternative treatment for knee pain. Key words: Genicular nerve blocks, chronic knee pain, genicular nerves, genicular nerve radiofrequency ablation

Patient Discomfort and Resident Confidence After Knee Intra-articular Injection Simulation Training: A Randomized Control Trial Study.

Teaching primary care providers how to perform musculoskeletal procedures has become increasingly important as more and more patients with orthopedic conditions present in primary care clinics. This study aims to evaluate whether targeted simulation model training in residency can increase residents’ comfort level in performing intra-articular knee injections and decrease the pain of the procedure, as reported by patients injected. Residents were randomized into intervention and control groups. The comfort level of the residents as well as the pain levels from the procedures, as reported by patients, was recorded. The mean comfort level for the intervention group was 1.2, compared with that in the control group, which was 2.13; P value was .047. The mean pain level in the intervention group was 1.8, whereas in the control group was 3.63; P value was .156. Simulation training may boost residents’ comfort level, but not necessarily decrease patient discomfort during intra-articular knee injections.

Breast Milk for Neonatal Vaccination Pain

A prospective, double-blinded (caregiver, researcher) randomised experimental study was conducted at the postnatal ward of a tertiary care hospital at Puducherry to identify the effect of twin intervention on pain among neonates receiving Bacillus Calmetteguaorine (BCG) vaccine. The outcome variable of pain level was assessed by using the Neonatal and infant pain Scale (NIPS) in terms of behavioural changes in behaviour and haemodynamic behaviour and variables like respiratory rate (RR), heart rate (HR), oxygen saturation (SpO2). One hundred and forty-five neonates fulfilling the inclusion criteria were randomly recruited into the study after informed parental consent. One ml of expressed breast milk (EBM) was given to the neonates by sterile syringe 2 min before BCG vaccination and the newborn kept in facilitated tucking position (FT) during vaccination procedure. The behavioural changes of neonates, duration of cry time and selected physiological parameters were recorded before BCG vaccination and after at 0, 3 and 5 min. It was found that the twin Intervention was effective in reducing the level of pain. The mean pain level for EBM group was 3.089 and for control study group it was 3.6. The median crying time was 53.511seconds in EBM at p&lt;0.001 which is less when compared with the control group. To conclude, the “twin intervention” (FT&amp; EBM) significantly reduces pain in neonates while they receive BCG vaccination.

Arthroscopic patellar release for treatment of chronic symptomatic patellar tendinopathy: long-term outcome and influential factors in an athletic population

BackgroundArthroscopic patellar release (APR) is utilized for minimally invasive surgical treatment of patellar tendinopathy. Evidence regarding long-term success following the procedure is limited. Also, the influence of age and preoperative performance level, are incompletely understood. The aim of this study was to investigate whether APR translates into sustained pain relief over a long-term follow-up in athletes undergoing APR. Furthermore, we analyzed if age influences clinical and functional outcome measures in APR.MethodsBetween 1998 and 2010, 30 competitive and recreational athletes were treated with APR due to chronic refractory patellar tendinopathy. All data were analyzed retrospectively. Demographic data, such as age or level of performance prior to injury were extracted. Clinical as well as functional outcome measures (Swedish Victorian Institute of sport assessment for patella (VISA-P), the modified Blazina score, pain level following exercise, return to sports, and subjective knee function were assessed pre- and postoperatively.ResultsIn total, 30 athletes were included in this study. At follow-up (8.8 ± 2.82 years), clinical and functional outcome measures such as the mean Blazina score, VISA-P, VAS, and subjective knee function revealed significant improvement compared to before surgery (P < 0.001). The mean time required for return to sports was 4.03 ± 3.18 months. After stratification by age, patients younger than 30 years of age yielded superior outcome in the mean Blazina score and pain level when compared to patients ≥30 years (P = 0.0448). At 8 years of follow-up, patients yielded equivalent clinical and functional outcome scores compared to our previous investigation after four years following APR.ConclusionIn summary, APR can be regarded a successful, minimally invasive, and sustained surgical technique for the treatment of patella tendinopathy in athletes. Younger age at surgery may be associated with improved clinical and functional outcome following APR.

Continuous Wound Infiltration After Hallux Valgus Surgery.

Hallux valgus surgery is associated with significant early postoperative pain. The aim of this study was to investigate the use of continuous wound infiltration (CWI) with ropivacaine for pain management after hallux valgus surgery. In this prospective, randomized, double-blind, and placebo-controlled single-center trial, 50 patients undergoing distal metatarsal osteotomy for idiopathic hallux valgus were allocated to CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h or placebo for 24 hours postoperatively. Average and peak pain levels on the verbal numeric rating scale (NRS; 1-10) during the first 48 hours after surgery were recorded as primary outcome parameters. Secondary outcome parameters included consumption of narcotics, clinical outcome, incidence of postoperative complications, and patient satisfaction. No significant difference in mean ( P = .596) and peak ( P = .353) postoperative pain level was found for CWI with either ropivacaine (mean NRS 1.9 ± 0.8; peak NRS 3.5 ± 2.0) or placebo (mean NRS 2.0 ± 0.7; peak NRS 3.9 ± 1.7) during the early postoperative course. Furthermore, no significant difference between both groups was detected regarding narcotic consumption ( P = .354) and all other secondary outcome parameters. Two severe complications (local dysesthesia with CWI, catheter accidentally fixed by a suture) and 5 catheter dislocations were observed. CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h for 24 hours after hallux valgus surgery did not reduce postoperative pain level in an inpatient setting. Level I, prospective randomized trial.

Functional results and isokinetic muscle strength in patients with Fraser type I floating knee treated with internal fixation

IntroductionAccording to Fraser’s description, ipsilateral femoral and tibial diaphyseal fractures are characterised as type I floating knee and have a better prognosis than fractures with joint involvement (type II). There are few reports of functional and muscle strength in these patients. The objective of this study was to evaluate the functional and isokinetic muscle strength of patients with type I floating knee undergoing femoral and tibial internal fixation. MethodsPatients with type I floating knee undergoing concomitant femoral and tibial internal fixation were invited for clinical evaluation. The parameters evaluated included the following: Karlstrom and Olerud score; Lysholm score; isokinetic thigh and hip muscle evaluation; knee range of motion; pain level; investigation of associated knee injuries by clinical evaluation and MRI; and types of complications. ResultsTwenty-one patients were included in the study; 11 of these were clinically evaluated, with a mean follow-up of 23.9 months. Six patients had an acceptable result according to the Karlstrom criteria, whereas eight patients had a poor result based on the Lysholm scale. The peak torque deficit was 61% for knee extensors, 37% for flexors and -9% for hip abductors. The mean pain level was 5.9. Three patients had a partial anterior cruciate ligament (ACL) injury; one patient had a posterior cruciate ligament (PCL) injury; and three patients had a meniscal injury. There were four cases of tibial or femoral nonunion at one year and two cases of chronic osteomyelitis. ConclusionPatients with type I floating knee had unsatisfactory functional results, significant knee extensor and flexor muscle strength deficits and a significant rate of complications at the two-year follow-up.

P.2.e.005 - Time-course antidepressant-like effect of repeated electroconvulsive shock as measured by the time spent immobile in the forced-swim test in rats

Comminuted fractures of the proximal ulna remain a great challenge in orthopedic surgery. The purpose of this study was to report the outcomes of comminuted proximal ulna fractures treated with a new construct type—anatomically preformed polyaxial locking compression plates.Between 2013 and 2016, 46 patients with isolated comminuted fractures were treated with a 2.7-/3.5-mm VA-LCP Olecranon Plate (Synthes, Umkirch, Germany). Of these, 44 were available for an assessment after a mean follow-up period of 2.5 years (range, 12-50 months). We evaluated range of motion, time to recovery, revision rate, and indications, as well as functional scores. Radiographs were analyzed.The study included 8 Mayo IB, 29 Mayo IIB, and 7 Mayo IIIB fractures. All fractures showed bony union, and only 2 revision surgical procedures were performed because of a new trauma. No other complications occurred. Mean range of motion was 139° (range, 105°-150°), and the mean pain level was less than 1 on a visual analog scale. Regarding elbow function, we found a mean Mayo Elbow Performance Score of 98; a mean Oxford Elbow Score of 44; and a mean Disabilities of the Arm, Shoulder and Hand score of 6. Of the plates, 41% were removed after an average time of 16 months, whereby a significant improvement in extension deficit was detected (P < .01). Ninety-five percent of all patients returned to their pretrauma sports level.The 2.7-/3.5-mm VA-LCP Olecranon Plate represents an effective option with excellent fracture reduction, sufficient stability for early postoperative functional rehabilitation, and a minimum of complications.

Clinical and radiological outcomes following radioscapholunate fusion

IntroductionRadioscapholunate (RSL) fusion is typically performed following wrist trauma. It addresses the pain caused by radiocarpal osteoarthritis but reduces the wrist's mobility. The objective of this study was to determine the long-term clinical and radiological outcomes of this procedure. Materials and methodsThis was a retrospective study of all wrists operated for RSL fusion in our surgery unit over a 12-year period. The clinical analysis consisted of joint amplitudes, grip strength, pain (VAS) and functional scores (PRWE, QuickDash, Mayo Wrist Score). The radiological analysis focused on bone fusion and the presence of midcarpal osteoarthritis. ResultsThis surgery procedure was performed on 48 wrists. Of these, 34 patients were available for review, including 6 who had subsequently undergone total wrist fusion after the RSL procedure. The average follow-up was 53 months. Flexion/extension and radioulnar deviation were 56° and 30°, respectively. Grip strength in the operated wrist was 71% of the contralateral wrist. The mean pain level was 3 out of 10. The PRWE, QuickDash and Mayo Wrist Score were 35.7, 44.5 and 57.2, respectively. Seventy-nine percent of patients were satisfied with the outcome. The fusion rate was 71%, the midcarpal osteoarthritis rate was 64% and the STT osteoarthritis rate was 46%. DiscussionReduced wrist range of motion in patients who have undergone RSL fusion helps to preserve satisfactory function in the majority of patients; however, the functional outcome scores point to some hindrance in day-to-day activities. Nonunion occurred in nearly one-quarter of patients and appears to be preventable by excision of the distal pole of the scaphoid (DPS). Midcarpal osteoarthritis develops in most wrists over the long-term and appears to be inevitable. ConclusionRSL fusion is a palliative procedure that preserves some of the wrist's mobility. However, it is a difficult procedure that has a significant nonunion rate. Excision of the DPS may contribute to lowering the nonunion rate.

Pain course after foot and ankle surgery

Category: Pain managment Introduction/Purpose: Most surgeons believe, that the postoperative pain course after foot and ankle surgery differs from other joints due to the initial protection and immobilization. The knowledge of the normal pain course after foot and ankle surgery is important to know for the surgeon and correctly inform patients preoperative and may help to identify abnormal postoperative healing courses. Methods: 180 patients were enclosed in a prospective study. 66,7% were female and 33.3% were male. All patients had primary surgery for foot and ankle diseases at a tertiary care foot and ankle center. The pain course was measured using a VAS over a one year period. The mean age was 53,2 (±13.6) years. Results: The mean pain level was 4.56 (± 2.0) preoperative. In the first postoperative week it was 3.5 (± 2.18) and declined until the 6th postoperative week to 1.57 (± 1.52) it increased again after the sixth week up to 1.95 (± 1.63) and decreased then again to 1.09 (± 1.51) one year postoperative. The pain level in patient with tendon surgeries tended to be higher in the first 12 weeks postoperative than that of patients with bony procedures. Conclusion: The pain course after Foot and ankle surgery shows a characteristic curve with a significant increase of the pain level after 6 weeks. A comprehensive patient information can increase satisfaction rates of the patient. Any abnormal postoperative pain course should arise suspection of a complicated healing period.

High-dose 8% capsaicin patch in treatment of chemotherapy-induced peripheral neuropathy: single-center experience

High-dose capsaicin patch is effective in treatment of neuropathic pain in HIV-associated neuropathy and diabetic neuropathy. There are no studies assessing effectiveness of high-dose capsaicin patch in treatment of chemotherapy-induced peripheral neuropathy. We sought to determine the effectiveness of treatment of pain associated with chemotherapy-induced peripheral neuropathy with high-dose capsaicin patch. Our study group consisted of 18 patients with clinically confirmed oxaliplatin-induced neuropathy. Baseline characteristic including underling disease, received cumulative dose of neurotoxic agent, neuropathic symptoms, prior treatment and initial pain level were recorded. Pain was evaluated with Numeric Rating Scale prior to treatment with high-dose capsaicin and after 1.8 day and after 8 and 12 weeks after introducing treatment. Patients were divided into two groups accordingly to the amount of neurotoxic agent that caused neuropathy (high sensitivity and low sensitivity group). Most frequent symptoms of chemotherapy-induced neuropathy were: pain (88.89%), paresthesis (100%), sock and gloves sensation (100%) and hypoesthesis (100%). Initial pain level was 7.45 ± 1.14. Mean cumulative dose of oxaliplatin after which patients developed symptoms was 648.07 mg/m2. Mean pain level after 12 weeks of treatment was 0.20 ± 0.41. When examined according to high and low sensitivity to neurotoxic agent patients with low sensitivity had higher pain reduction, especially after 8 days after introducing treatment (69.55 ± 12.09 vs. 49.40 ± 20.34%; p = 0.02) and after 12 weeks (96.96 ± 5.56 vs. 83.93 ± 18.59%; p = 0.04). High-dose capsaicin patch is an effective treatment for pain associated with chemotherapy-induced neuropathy in patients treated with oxaliplatin. Patients with lower sensitivity to neurotoxic agents have better response to treatment and pain reduction.

Causes, trends and severity of musculoskeletal injuries in Ghana

BackgroundMusculoskeletal [MSK] injuries are common causes of long-term pain and physical disability which affect many people worldwide. The economic and social impacts on the individual, society and national health systems are enormous making a matter of public health concern. Therefore, this study examined the causes and extent of MSK injuries in a referral hospital in Ghana.MethodsA prospective study design with consecutive sampling method was used to recruit patients admitted at Trauma Unit as well as those receiving orthopaedic reviews at St. Joseph’s Orthopaedic Hospital over a ten-month period. A structured questionnaire, Visual Analogue Scale (VAS) and Abbreviated Injury Scale (AIS) were used to collect data which were analysed descriptively using SPSS version 20.ResultsA total of 269 MSK injury patients were identified - of these, 137 (50.9%) males with an average age of 38 years (SD = 19.88). Nearly half (49.1%) of the injuries sustained were fractures, and common causes were vehicular crash 113 (42.0%) and fall 68 (25.3%). Body parts affected most were the knee (19.62) and the mean levels of pain for all injuries were 6.04 ± 2.44 and 3.25 (±1.50) respectively.ConclusionGhana needs a healthy population to steer its development trajectory. Policy makers in Ghana should pay attention to both preventive as well as management of MSK injuries, or else, most of the country’s working class could live with lasting effects of injuries which may have significant impacts on the economy.

Outcomes after Arthroscopic Debridement of the Triangular Fibrocartilage Complex in Adolescents.

Background To the best of our knowledge, we are not aware of any reports focusing on results of arthroscopic debridement of triangular fibrocartilage complex (TFCC) tears in immature patients. Purpose The purpose of this study was to evaluate our results after arthroscopic debridement of TFCC tears in adolescents. Materials and Methods We retrospectively identified all patients of 18 years or less, who received an arthroscopic TFCC debridement due to a traumatic or degenerative tear according to Palmer. These cases were clinically re-evaluated after a mean period of 6.7 years (SD ± 3.9 years). All patients completed the Modified Mayo Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) inventory, and Patient-Rated Wrist Evaluation (PRWE). Results Thirteen adolescent patients (mean age: 15.6 ± 2.2 years at surgery) were included. The mean MMWS increased significantly from 70 ± 13.6 to 90 ± 6.5 after the TFCC debridement; mean postoperative DASH and PRWE scores of 17 ± 15.2 and 21 ± 18.5, respectively, indicated good and excellent outcomes for the majority of the cohort. The mean pain level decreased significantly from a mean of 5.7 ± 2.0 to 1.8 ± 2.0 at follow-up. Six patients needed a reoperation to achieve a successful outcome. Conclusion Arthroscopic debridement of TFCC tears, performed as a concomitant wrist surgery in adolescents, efficiently reduced wrist pain and yielded good to excellent results in the long term. However, under certain circumstances, its results are unpredictable and further surgery may be necessary to eventually achieve the satisfying outcomes. Further studies are needed to confirm these findings. Level of Evidence Level IV, therapeutic case series.

Combatting pain after orthopedic/trauma surgery- perioperative oral extended-release tapentadol vs. extended-release oxycodone/naloxone

BackgroundHigh post-operative pain scores after “minor” orthopedic/trauma surgery are in part attributed to inadequate prescription of opioid analgesics. Novel concepts aiming to achieve sufficient analgesia while minimizing opioid-related side effects by avoiding fluctuating plasma levels are based on perioperative oral administration of extended-release opioids beginning with the first dose pre-operatively. This is the first study to evaluate analgesic efficacy and side effect rates of extended-release tapentadol compared to oxycodone/naloxone following orthopedic/trauma surgery.MethodsThis randomized, observer-blinded, active-controlled prospective clinical trial had 2 co-primary endpoints: (1) Analgesic efficacy: Mean pain level on a numeric rating scale (NRS) from 0 to 10 during exercise over 5 days. (2) Safety: Side effect sum score of the following events: Nausea, vomiting, constipation, sedation, vertigo, somnolence. The study was powered to detect superiority of tapentadol for at least one endpoint pending statistical proof of non-inferiority for both endpoints in a first step.ResultsTwo hundred sixty-six trauma patients were randomized to receive either tapentadol (n = 133) or oxycodone/naloxone (n = 133). Analgesic efficacy: Mean (±SD) daily pain levels in the first five post-operative days were 2.8 ± 1.3 in both groups. Mean maximum pain intensity during exercise in the first 24 h after surgery was 3.8 ± 1.9 (tapentadol) and 3.8 ± 2.1 (oxycodone/naloxone). Statistically tapentadol was non-inferior but not superior to oxycodone/naloxone. Safety: Vomiting on day 1 occurred in 11%, constipation in 35% of the tapentadol patients and in 16% and 30% of the oxycodone/naloxone patients (p = 0.60 and 0.33), respectively. The incidence of sedation/ vertigo was <10%, that of somnolence <2% in both groups (p > 0.3, respectively). The sum score of side effect events was 51% in the tapentadol vs. 49% in the oxycodone/naloxone group; risk difference 3% [95% CI, −8 to 14%]; p = 0.6). Non-inferiority of tapentadol could not be concluded as the pre-defined non-inferiority margin was exceeded.ConclusionsWith both concepts, mean maximum pain intensity during exercise within the first 24 h after orthopedic/trauma surgery was reduced to a score of <4. This analgesic efficacy came at the cost of mainly gastro-intestinal side effects. Thus, we now use a prophylaxis against nausea and vomiting and pre-emptive laxatives as part of these concepts.Trial registrationhttps://eudract.ema.europa.eu (EudraCT- Nr. 2011–003238-15); October 24th, 2012.

Lipoprotein apheresis in patients with peripheral artery disease and lipoprotein(a)-hyperlipoproteinemia: 2-year follow-up of a prospective single center study

ObjectiveElevated plasma levels of lipoprotein(a) [Lp(a)], referred to as lipoprotein(a)-hyperlipoproteinemia [Lp(a)-HLP], are an independent risk factor for atherosclerosis. Lipoprotein apheresis (LA) enables an effective reduction of Lp(a) plasma levels. The present study investigates the effects of LA in patients with Lp(a)-HLP and peripheral artery disease (PAD). MethodsTen patients with isolated Lp(a)-HLP and severe PAD and who had recently undergone a revascularization (index procedure) were prospectively included in this observational single center study. All patients received weekly LA. Ankle-brachial-index (ABI), transcutaneous partial oxygen pressure (tcpO2), pain level, and walking distance were assessed at baseline and at the follow ups scheduled 1, 3, 6, 12, and 24 months after initiation of LA. The number of revascularizations within 12 months prior and within 24 months after the index procedure was determined. ResultsAs early as 1 month after initiation of LA, all investigated parameters had improved significantly compared to baseline. This improvement was further substantiated under LA throughout the entire follow-up period. Comparing baseline results with the 24-month follow-up, the average ABI increased from 0.53 ± 0.15 to 0.97 ± 0.08 (P < 0.001). The mean tcpO2 also increased from 42.9 ± 2.3 mmHg to 61 ± 4.6 mmHg (P < 0.001). The improved perfusion led to a reduction of the mean pain level from 7.0 ± 1.5 to 1.1 ± 0.4 (P < 0.001) on a visual analogue scale (VAS) and an extension of the mean walking distance from 87 ± 60 m to 402 ± 119 m (P < 0.001). All patients suffered from severe PAD with a high number of revascularizations in the 12 months prior to the index procedure (35 procedures in 120 patient-months). Since initiation of LA, the number of revascularizations dropped significantly and remained very low during the entire follow-up period (2 procedures in 229 patient-months, P < 0.001). ConclusionIn patients with Lp(a)-HLP and severe PAD, LA results in sustained improvement of circulation, pain level and walking distance. The number of repeat revascularizations is strongly reduced under LA treatment.

Functional Outcomes of Childhood Selective Dorsal Rhizotomy 20 to 28 Years Later

BackgroundSelective dorsal rhizotomy (SDR) is a surgical method used to treat childhood spastic cerebral palsy (CP). However, the effects of early SDR on functional outcomes and quality of life decades later in adulthood remains to be elucidated.ObjectivesTo evaluate the long-term outcomes in terms of satisfaction and mobility of adult patients who received childhood SDR.MethodsAdult patients who received SDR in childhood were surveyed. The survey questionnaire asked about demographic information, quality of life, health outcomes, SDR surgical outcomes, ambulation, manual ability, pain, braces/orthotics, post-SDR treatment, living situation, education level, and work status.ResultsOur study included 95 patients. The age that patients received SDR was between two and 18 years. The age at the time of survey was between 23 and 37 years (mean ± S.D., 30.2 ± 3.6 years). Post-SDR follow-up ranged from 20 to 28 years (mean ± S.D., 24.3 ± 2.2 years). Seventy-nine percent of patients had spastic diplegia, 20% had spastic quadriplegia, and one percent had spastic triplegia. Ninety-one percent of patients felt that SDR impacted positively the quality of life and two percent felt that the surgery impacted negatively the quality of life after SDR. Compared to pre-operative ambulatory function, 42% reported higher level of ambulation and 42% ambulated in the same level. Eighty-eight percent of patients would recommend the procedure to others and two percent would not. Thirty-eight percent reported pain, mostly in the back and lower limbs, with mean pain level 4.2 ± 2.3 on the Numeric Pain Rating Scale (NPRS). Decreased sensation in patchy areas of the lower limbs that did not affect daily life was reported by eight percent of patients. Scoliosis was diagnosed in 31%. The severity of scoliosis is unknown. Only three percent of them underwent spinal fusion. Fifty-seven percent of patients required some orthopedic surgery after SDR. The soft-tissue tendon lengthening procedures included lengthening on hamstrings, Achilles tendons or adductors. Out of all bone procedures, 24% of patients had hip surgery, five percent had knee surgery, and 10% had derotational osteotomies. No late side effects of SDR surgery were reported in this survey.ConclusionsIn our 95 adult patients who received SDR in childhood, the surgery had positive effects on the quality of life and ambulation 20-28 years later. There were no late complications of SDR surgery.

Ultrasound-Guided Percutaneous Needle Fenestration and Corticosteroid Injection for Anterior and Anterolateral Ankle Impingement.

Ankle impingement is a common cause of chronic ankle pain. We retrospectively studied the effectiveness of ultrasound-guided percutaneous needle fenestration of the pathological soft tissues combined with corticosteroid injection to treat this condition. We administered a telephone survey to patients who underwent the procedure. Patients were asked questions on the Foot Function Index and queried about their overall satisfaction with the procedure on a scale of 0 (completely unsatisfied) to 10 (very satisfied). Forty-nine patients participated in the survey: 26 women and 23 men, mean age 42.7 years (range, 19-65 years). Impingement was anterior in 26/49 (53.1%), anterolateral in 14/49 (28.6%), and both in 9/49 (18.4%). Mean pain level before the procedure was 6.76 ± 1.84 and after the procedure was 2.73 ± 2.21. Reported pain scale levels declined by 4.02 ± 2 units after the procedure (P < .0001). Patient's overall satisfaction was 7.9 ± 2.44. Ultrasound-guided percutaneous needle fenestration and corticosteroid injection appears to be an effective nonoperative alternative for treatment of anterior and/or anterolateral ankle impingement. Level IV.