Mean Postoperative Visual Analog Scale Research Articles

Results in 7 Cases of Neurectomy With a Transverse Plantar Approach for Primary Morton’s Neuroma

Surgery is often performed for Morton’s neuroma when conservative treatment is ineffective. This study aimed to describe the surgical results of Morton’s neuroma. Six patients (7 feet) underwent neurectomy via a transverse plantar incision in the forefoot. Changes in perceived pain, function, and patient satisfaction were measured with a Visual Analog Scale, the American Orthopaedic Foot and Ankle Surgery Scale, and the Coughlin score, respectively. Six feet had neuromas in the third intermetatarsal space and 1 foot had neuromas in the third and second spaces. The mean preoperative and postoperative Visual Analog Scale scores were 7.14±0.69 and 1.86±0.69, respectively. The mean preoperative and postoperative American Orthopaedic Foot and Ankle Surgery scores were 69.71±6.73 and 94.86±3.93, respectively. Four patients were very satisfied, and 2 patients were just satisfied. The plantar surgical approach for the treatment of Morton’s neuroma has few complications with good functional results and patient satisfaction in this case series. Level of Evidence: Diagnostic Level IV—retrospective case series. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of minimally invasive osteosynthesis of intertrochanteric fractures with dynamic hip screw: A prospective case series

BackgroundIntertrochanteric fractures are a public health concern, especially in geriatric patients. Early surgical management is crucial to allow early mobilization, which helps reduce the disability and increase patients' survival. In this article, we report the outcomes of minimally invasive osteosynthesis of intertrochanteric fractures with dynamic hip screw (DHS). MethodsThe present study was a prospective case series of patients who had intertrochanteric fractures treated with minimally invasive DHS technique. Postoperative patient satisfaction rate was evaluated using the visual analog scale (VAS) of pain. Functional outcomes were evaluated using the Harris hip score (HHS) and the Merle-d'Aubigne-Postel (MDP) scoring system at 12 months of follow-up. Satisfactory results were considered with HHS of ≥80 points and MDP scores of ≥15. Postoperative complications were noted. ResultsIn this study, 70 patients were included, 41 (58.6%) males and 29 (41.4%) females, with an average age of 69.3 ± 8.3 years. The mean length of hospital stay was 2.1 ± 0.9 days. The average follow-up period was 23.9 ± 7.1 months. The mean time to radiological union was 16.8 ± 1.9 weeks. The mean postoperative VAS score for pain was 2.5 ± 1.1. The mean HHS was 87.1 ± 4.7 points and the mean MDP score was 15.6 ± 2.3 at 12 months follow-up. An average of 10.6 ± 2.9 weeks was required for full weight bearing. ConclusionThe minimally invasive DHS technique effectively treats intertrochanteric fractures with minimal incision, less bleeding, shorter operative time, early discharge from hospital, faster rehabilitation, and favorable functional outcomes.

Sacroiliac Joint Fusion: Fusion Rates and Clinical Improvement Using Minimally Invasive Approach and Intraoperative Navigation and Robotic Guidance.

This study adopted a retrospective study design. This study was designed to describe the fusion rate and technique and patient subjective improvement after sacroiliac (SI) joint fusion using a minimally invasive surgical (MIS) approach. The SI joint can mimic radicular or discogenic pain localized to the lower back, gluteal region, or sacral region, posing a challenge in the diagnosis and treatment. This study determines the radiological fusion rate and patient reported subjective clinical outcomes of SI joint fusion using an MIS approach, comparing the use of the Rialto SI joint fusion system (Medtronic, Minneapolis, MN, USA) with the help of the Stealth Navigation System with the use of ExcelsiusGPS Robotic Navigation Platform (Globus Medical Inc., Audubon, PA, USA) using SI-LOK screws (Globus Medical Inc.). In this retrospective study, 43 consecutive patients who underwent SI joint fusion between August 2017 and February 2020 were enrolled; 60 SI joints were fused. The patients' fusion was documented on computed tomography or X-rays, and Visual Analog Scale (VAS) scores were used to determine patient subjective clinical outcomes. A total of 60 joints were fused, including 26 joints fused using robotic guidance and 34 joints fused using the Stealth Navigation System. Student t-test was used to compare the mean preoperative VAS score (7.52±1.3) with the mean postoperative VAS score at the 12-month follow-up (1.43±1.22) (p<0.05). The SI joint fusion rate using this technique was 61% at 6 months, 96.4% at 12 months, and 100% at 18 months. The use of navigation guidance or robotic assistance enables accurate percutaneous screw placement across the SI joint. The use of bone morphogenetic protein in the screw bore hastens fusion across the joint, improving patient-perceived pain.

Evaluation of Efficacy of Endovenous Radio Frequency Ablation for Varicose Veins in Industrial Workers—A Prospective Study

AbstractIntroduction The disease of varicose veins is a common vascular condition affecting one out of five in world population. Although conventional surgical treatments were considered the gold standard, they were fraught with many complications. Endovenous thermal interventions like endovenous radio frequency ablation (RFA) have largely superseded traditional surgery as the gold standard treatment as it is minimally invasive. Our initial experience with this treatment modality is presented along with the review of literature.Aim Our aim was to evaluate the efficacy, safety, clinical outcomes, and health economic benefits of endovenous RFA for varicose veins in our setup.Materials and Methods It was a prospective observational study conducted by the Department of General surgery at ESIC Medical College and Hospital, Hyderabad, India, from September 2020 to February 2021. Thirty consecutive patients with primary varicose veins were evaluated by detailed history, clinical examination, and venous Doppler study of the lower limbs. The procedure was performed under spinal anesthesia and Doppler ultrasound guidance using the ClosureFast (Medtronic) radio frequency segmental ablation system. Additionally, multiple stab phlebectomies were performed to deal with tributary varices in required cases. Various intraoperative (length of vein ablated and operative time) and postoperative (complications and return to work) variables were studied. Postoperative follow-up at 1,8,24 weeks was done clinically and using Doppler ultrasound to look for the recanalization of vein. The collected data were entered in Microsoft Excel spreadsheet and analyzed using descriptive statistics.Results The mean (standard deviation) age of patients was 39.1 (8.7) years. Ten patients had C2 disease, six C3, eleven C4, and three had C6 disease. The mean postoperative visual analog scale score on day 1 was 1.4. Mean return to normal activity time was 1.3 days. Average return to work time was 2.1 days. The post-procedure total occlusion rate at 24 weeks follow-up was 96%.Conclusion Endovenous RFA is a safe and effective minimally invasive modality for treating lower limb varicose veins, providing health economic benefits to patients.

Plantar Plating in the Modified Lapidus Procedure: Evaluation of Function and Impairment of the Tibialis Anterior Tendon

The modified “Lapidus” procedure (MLP) describes the arthrodesis of the first tarsometatarsal joint. We investigate if there are detectable changes of the tendon or the function of the muscle and clinical outcome after MLP. We reviewed 22 feet. All patients underwent magnetic resonance imaging (MRI) at an average of 27 (range, 12-49) months. Clinical outcome was evaluated using the European Foot and Ankle Society score. Strength was measured and complications were assessed. MRI revealed signs of tendinopathy of the tibialis anterior tendon in 13 feet (59%). The mean total European Foot and Ankle Society score at final follow-up was 17 (range, 6-24) points. The mean postoperative Visual Analog Scale score was 1.4 (range, 0-5). Range of motion and force data were not significantly different to the contralateral side. In conclusion, MRI showed signs of tendinopathy in 59%, which does not seem to affect clinical outcome, but has to be considered when choosing the desired implant and placement. MLP leads to high patient satisfaction rates and significant improvement at midterm follow up.

Cemented versus uncemented reverse shoulder arthroplasty for acute proximal humeral fractures.

The purposes of this study were (1) to compare postoperative range of motion (ROM) and functional outcomes in patients with proximal humeral fractures operated on with cemented or uncemented reverse shoulder arthroplasty (RSA), (2) to compare the rate of tuberosity healing between cemented and uncemented stems, (3) to determine whether there are significant differences in functional outcomes between patients with healed tuberosities and those with unhealed tuberosities, and (4) to compare complications and revision rates in patients with cemented RSA and uncemented RSA. A cemented RSA was performed early in the study period, which represented a historical cohort (January 2015 to January 2017), followed by a transition to the uncemented RSA later in the study period (February 2017 to February 2019). We excluded 22 cases from postoperative evaluation because of fracture sequelae, age < 65 years, death, and institutionalization; 3 patients were lost to follow-up. The remaining 67 cases (32 cemented and 35 uncemented) underwent clinical and radiographic evaluation by 2 independent fellowship-trained shoulder surgeons. Patients were assessed regarding ROM and the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and Single Assessment Numeric Evaluation score. All intraoperative and postoperative complications were recorded. The mean follow-up period was 41 months (range, 24-72 months), and the mean age was 74 years (range, 65-84 years). Mean postoperative active elevation, internal rotation, external rotation in abduction, and external rotation in adduction were 130° (±15°), 27° (±5°), 28° (±10°), and 16° (±6°), respectively. The mean postoperative visual analog scale, American Shoulder and Elbow Surgeons, Constant, and Single Assessment Numeric Evaluation scores were 1.8 (±0.8), 74 (±6), 58 (±11), and 74% (±8), respectively. There were no significant differences in final ROM and functional scores between the cemented and uncemented groups. The rate of tuberosity healing did not vary significantly in relation to whether the stem was cemented. The subgroup of patients with tuberosity healing presented significantly better active elevation, external rotation, and Constant scores than the subgroup without tuberosity healing. There were 5 complications (7%) and no cases of aseptic humeral stem loosening. In the short term (mean, 41 months), there were no significant differences in postoperative ROM, functional outcomes, complications, and revisions between patients operated on with cemented RSA and those operated on with uncemented RSA for proximal humeral fractures. Patients with healed tuberosities presented significantly better ROM and functional scores than patients without tuberosity healing. The cementation of the stem did not significantly affect the rate of tuberosity healing.

Unilateral Biportal Endoscopy for Decompression of Extraforaminal Stenosis at the Lumbosacral Junction: Surgical Techniques and Clinical Outcomes.

ObjectiveThe aims of this study were to describe the unilateral biportal endoscopic (UBE) technique for decompression of extraforaminal stenosis at L5–S1 and evaluate 1-year clinical outcomes. Especially, we evaluated compression factors of extraforaminal stenosis at L5–S1 and described the surgical technique for decompression in detail. MethodsThirty-five patients who underwent UBE decompression for extraforaminal stenosis at L5–S1 between March 2018 and February 2019 were enrolled. Clinical results were analyzed using the MacNab criteria, the visual analogue scale (VAS) for back and leg pain, and the Oswestry Disability Index (ODI). Compression factors evaluated pseudoarthrosis within the transverse process of L5 and ala of sacrum, disc bulging with or without osteophytes, and the thickened lumbosacral and extraforaminal ligament. ResultsThe mean back VAS was 3.7±1.8 before surgery, which dropped to 2.3±0.8 at 1-year postoperative follow-up (p<0.001). There was a significant drop in postoperative mean VAS for leg pain from 7.2±1.1 to 2.3±1.2 at 1 year (p<0.001). The ODI was 61.5 before surgery and 28.6 (p<0.001). Pseudoarthrosis between the transverse process and the ala was noted in all cases (35 of 35, 100%). Pure disc bulging was seen in 12 patients (34.3%), and disc bulging with osteophytes was demonstrated in 23 patients. The thickened lumbosacral and extraforaminal ligament were identified in 19 cases (51.4%). No complications occurred in any of the patients. ConclusionIn the current study, good surgical outcomes without complications were achieved after UBE decompression for extraforaminal stenosis at L5–S1.

Efficacy of Aloe Vera Gel in Dry Socket After Removal of Mandibuler Third Molar

Objective: To evaluate the effectiveness of Aloe Vera gel in management of dry socket after surgical removal of 3rd molar. Study Design &amp; Setting: From December 2020 to November 2021, a descriptive research was conducted in the Section of Oral &amp; Maxillofacial Surgery, Liaquat University of Medical &amp; Health Sciences, Jamshoro, Hyderabad, Sindh. Methodology: Total 70 patients were included and divided equally in two groups i.e. Group-A (Alveora dressing) and Group-B (Controls). Dry socket, pre-operative assessment was carried out on the basis of pain Visual analog scale (VAS) and healing index. Socket was irrigated with sterile saline 0.9% in experimental group. In control group, patient were given tablet Panadol 1gm SOS. Patients were evaluated post operatively at 1st, 2nd, and 3rd day on the basis of pain (VAS) and healing index. Results: In group-A mean postoperative VAS at day-1, day-2 and day-3 was 6.69±2.59, 3.17±2.39 and 1.14±1.03 respectively. In group-B it was 7.77±2.03, 6.97±2.14 and 4.57±2.57. In group-A, mean postoperative healing scale at day-1, day-2 and day-3 was 2.83±0.56, 3.49±0.61 and 4.37±0.73 respectively and in group-B it was 2.31±0.58, 2.63±0.69 and 3.26±0.65 respectively. Significant association of pain intensity at day-2 and day-3 and healing index (at day-1, day-2 and day-3) was observed. Conclusion: Aloe Vera gel significantly reduced postoperative pain and improve healing index. Keywords: Effectiveness, Aloe Vera Gel, Dry Socket, Surgical Removal, Third Molar

Tratamento da lesão da sindesmose tibiofibular distal associada às fraturas do tornozelo com suture button

Objective To evaluate the results obtained from the surgical treatment of malleolar ankle fractures associated with distal tibiofibular syndesmosis (DTFS) injury submitted to conventional surgical procedure for fracture fixation and DTFS fixation by suture button (SB). Methods Forty-nine patients were retrospectively evaluated, with a mean age of 45 years old and a mean follow-up of 34.1 months. Clinical and functional evaluation was based on the visual analogue scale (VAS) and on the American Foot and Ankle Society Score (AOFAS) for ankle and hindfoot, return to routine activities, and return to sport. Results The postoperative mean AOFAS and VAS were, respectively, 97.06 (confidence interval [CI 95%: 95.31–98.81] and 0.16 [CI 95% 0,04 – 0,29]. All patients returned to previous daily activities, and only 12 showed some residual symptom. There was no postoperative instability in any patient. Forty-six patients returned to sports activities and, of these, only 1 did not return to the level prior to the injury. Only two patients presented SB-related alterations. There was no report of dissatisfaction. Conclusion In malleolar fractures of the ankle with DTFS injury, the fixation of syndesmosis with SB demonstrated excellent postoperative results. Level of Evidence IV, retrospective case series.

Feasibility and Safety of Three-Port Laparoscopic Cholecystectomy Compared to Four-Port Laparoscopic Cholecystectomy.

BackgroundThe standard four-port laparoscopic cholecystectomy (LC) is the gold standard procedure. The various clinical trials and reports in the literature have suggested that the three-port technique LC can be done safely with acceptable results.Still, that the three-port LC offers any added benefits to the patient is a controversial issue especially in view of safety and feasibility. In this study, we report the experience of three-port LC compared to four-port LC technique, its safety, feasibility and outcomes.Materials and methodsA prospective randomized study was conducted between two groups which included 165 cases - 93 patients were included in three-port LC (Group A) and 72 patients in four-port LC (Group B). Operative time, intraoperative complications, postoperative pain, length of hospital stay, analgesics requirement, conversion to open and return to normal activities were parameters of evaluation.ResultsDemographic data was comparable in both the groups. Three-port LC Group A had lesser post-operative pain and analgesics requirements. The mean postoperative pain visual analogue scale (VAS) score on day 1 was (4.16 and 6.24), on day 7 was (1.26 and 1.81) in three-port group and in four-port LC group, respectively. The mean days of analgesics requirement were 2.56 days and 4.21 days among three-port group and four-port group, respectivelyLength of hospital stay was less and returning to work was early in three-port group. There was no statistical difference in operative time. The mean operative time among three-port LC group A and four-port LC group B was 36+/-8.6 minutes (30-68) and 39+/-7 minutes (30-90), respectively. The overall outcomes were comparable to four-port LC.ConclusionThree-port LC is a feasible and safe procedure for LC with satisfactory outcomes like lesser postoperative pain, postoperative stay and less scars, when performed by experienced hands, especially in acute cholecystitis. The use of fourth port should be done when required in a difficult situation.

Clinical Outcomes of Arthroscopic Management in the Treatment of Advanced End-stage Internal Derangement Wilkes V Cases of the Temporomandibular Joint

PurposeInternal derangement of the temporomandibular joint (TMJ) is 1 of the most common forms of temporomandibular joint disorders. The clinical efficacy and patient outcomes associated with TMJ arthroscopy have been well-documented for articular disorders (I-IV) of internal derangement.1,2 No studies to date, however, have focused specifically on patient outcomes of arthroscopic management of end-stage articular disorder Wilkes V cases. The purpose of the present study was to evaluate the clinical outcomes of operative arthroscopic management of end-stage cases of internal derangement of the TMJ. Patients and methodsThis is a retrospective case series. Inclusion criteria were patients with internal derangement articular disorder Wilkes V, denoted by articular disc perforation, crepitation, pain, and associated degenerative bone changes such as erosion and flattening of the mandibular condylar head. Exclusion criteria were patients with pre-existing primary arthritis, patients with internal derangement articular disorders I-IV, and patients with psychiatric disorders. Outcome variables were maximum voluntary mouth incisal opening (MIO), visual analog scale assessment for patient self-reported pain, and jaw functional-limitation index scores (0-10). Other variables, including patient age and gender, were evaluated in relation to the outcomes. ResultsThirty-seven patients with internal derangement articular disorder Wilkes V were identified in the study (total of 58 sides). Mean age was 40 years old (range 23 to 65 years old); 28 of the patients were female and 9 males. The mean preoperative MIO was 26mm, and the mean preoperative visual analog scale for pain and functional limitation scores were both 8 out of 10. Operative arthroscopic surgery was conducted (Figures 1 and 2). The mean duration of postoperative follow-up was 8 months (1.5-17 months). Postoperatively, mean MIO was 37mm (32-51mm range). Mean postoperative visual analog scale for pain and functional limitation scores improved to 3 and 2, respectively, out of 10. ConclusionThe results from the present study demonstrated that operative arthroscopic intervention effectively increases ROM, reduces pain, and improves functional limitation and jaw use in end-stage advanced internal derangement articular disorder Wilkes V of the TMJ. This work demonstrates the efficacy of this procedure in advanced degenerative end-stage internal derangement cases and is a viable treatment to preserve articular anatomy and improve joint function. Further continued multi-center rigorous study and evaluation is required to demonstrate the reproducibility of this technique and associated outcomes in the Wilkes V internal derangement patient population.

Gall Bladder Retrieval through Umbilical versus Epigastric Port in Conventional Four Ports Laparoscopic Cholecystectomy.

Introduction: Laparoscopic cholecystectomy has become the gold standard treatment for symptomatic gall stone disease all over the world. In laparoscopic cholecystectomy gall bladder is traditionally removed through umbilical port. In this approach surgeon has to change his position and telescope has to be changed in xiphoid port. Another approach to remove the gallbladder is through 10mm xiphoid port without changing position of telescope and surgeon. Both approaches are compared for their pros and cons regarding post-operative pain at site of removal. Study Design: Randomized control study. Setting: Department of surgery of Allama Iqbal medical college/ Jinnah hospital Lahore. Period: August 2017 to February 2018. Material &amp; Methods: To compare mean post-operative pain in gall bladder retrieval through umbilical versus xiphoid port in four ports laparoscopic cholecystectomy for acute cholecystitis. Patient were divided in two equal groups with first group had their gall bladder retrieved through umbilical port while the other underwent retrieval through xiphoid port. Standard analgesia was used in both groups and post-operative outcome was noted. Results: A total 70 patient with equal distribution in two groups were enrolled to compare post-operative pain at port site comparing umbilical versus xiphoid process. Mean post-operative pain visual analogue scale (VAS) was as lower (p&lt;0.0001) at 1, 6, 12 &amp; 24 hrs. In umbilical port group as compared to xiphoid port group. Conclusion: Mean post-operative pain in gall bladder retrieval umbilical port give advantage in post-operative period regarding significantly reduced pain when compared with xiphoid port in four ports laparoscopic cholecystectomy for acute cholecystitis in selective cases.

Is Internal brace augmentation a gold standard treatment compared to isolated Modified Brostrom Gould repair for chronic lateral ligament ankle instability? Effect on functional outcome and Return to preinjury activity: A retrospective analysis

IntroductionModified Brostrom Gould (MBG) repair is widely accepted procedure for chronic lateral ankle instability (CLAI), but there are limitations with regards to strength of repair and risk of reinjury and complications. Internal brace has been recently used as augmentation of standard MBG repair. It provides stronger construct, facilitates early mobilisation and protects repaired ligament with minimal surgical morbidity. The aim of present study is to compare the outcome of MBG repair without and with Internal brace augmentation (IB) in CLAI. MethodsRetrospective analysis of 172 patients with CLAI who underwent MBG repair with or without IBA between November 2017 and October 2019. Patients were evaluated for Visual analogue scale (VAS), Manchester-oxford foot questionnaire (MOxFQ), Patients subjective satisfaction and return to preinjury activity level. Results148 patients were included in the study with 87 in MBG group and 61 in IB group. The mean age, average injury-surgery interval and mean follow up duration was 40.6 ± 11.2 vs 37.5 ± 14.7 years, 13.1 ± 10.3 vs 14.1 ± 8 months and mean follow up duration of 24.2 ± 5.1 vs 20.7 ± 6.0 months respectively (p > 0.05). The mean time to return to preinjury activity level was significantly better in IB group compared to MBG group of 12.1 ± 2.3 vs 20.3 ± 3.9 weeks, p < 0.001. 55 (90.2%) patients in IB and 73 (83.7%) in MBG group return to preinjury activity level. Mean postoperative VAS score (1.9 ± 1.5 vs. 1.7 ± 1.4, p = 0.428), Mean MOxFQ score (19.7 ± 22.2 vs. 18.2 ± 15.4, p = 0.674) showed no significant difference between MBG and IB group respectively, at final follow up. ConclusionThe use of IB augmentation with MBG repair showed significantly better outcome in terms of early rehabilitation and return to preinjury activity level compared to isolated MBG repair. The functional outcome and VAS score were better in IB group compared to MBG group with no significant difference. Level of evidenceLevel IV retrospective study.

Lumbar spine fusion outcomes using a cellular bone allograft with lineage-committed bone-forming cells in 96 patients

BackgroundInstrumented posterior lumbar fusion (IPLF) with and without transforaminal interbody fusion (TLIF) is a common treatment for low back pain when conservative interventions have failed. Certain patient comorbidities and lifestyle risk factors, such as obesity and smoking, are known to negatively affect these procedures. An advanced cellular bone allograft (CBA) with viable osteogenic cells (V-CBA) has demonstrated high fusion rates, but the rates for patients with severe and/or multiple comorbidities remain understudied. The purpose of this study was to assess fusion outcomes in patients undergoing IPLF/TLIF using V-CBA with baseline comorbidities and lifestyle risk factors known to negatively affect bone fusion.MethodsThis was a retrospective study of de-identified data from consecutive patients at an academic medical center who underwent IPLF procedures with or without TLIF, and with V-CBA. Baseline patient and procedure characteristics were assessed. Radiological outcomes included fusion rates per the Lenke scale. Patient-reported clinical outcomes were evaluated via the Oswestry Disability Index (ODI) and Visual Analog Scale (VAS) for back and leg pain. Operating room (OR) times and intraoperative blood loss rates were also assessed.ResultsData from 96 patients were assessed with a total of 222 levels treated overall (mean: 2.3 levels) and a median follow-up time of 16 months (range: 6 to 45 months). Successful fusion (Lenke A or B) was reported for 88 of 96 patients (91.7%) overall, including in all IPLF-only patients. Of 22 patients with diabetes in the IPLF+TLIF group, fusion was reported in 20 patients (90.9%). In IPLF+TLIF patients currently using tobacco (n = 19), fusion was reported in 16 patients (84.3%), while in those with a history of tobacco use (n = 53), fusion was observed in 48 patients (90.6%). Successful fusion was reported in all 6 patients overall with previous pseudarthrosis at the same level. Mean postoperative ODI and VAS scores were significantly reduced versus preoperative ratings.ConclusionThe results of this study suggest that V-CBA consistently yields successful fusion and significant decreases in patient-reported ODI and VAS, despite patient comorbidities and lifestyle risk factors that are known to negatively affect such bony healing.

The most effective local infiltration analgesic (LIA) in reducing overall opioid use and nausea in the acute postoperative period of shoulder arthroplasty patients; a prospective, double-blind, randomized observational study

IntroductionEffective pain management in the immediate postoperative period is a crucial first step in the treatment of shoulder arthroplasty patients. Previous studies suggested that local infiltrative analgesia (LIA), specifically with Liposomal Bupivacaine (LB), is equivalent to interscalene nerve block (ISNB) for postoperative pain management. This prospective, randomized, double-blinded study seeks to measure the difference in efficacy between the 3 widely-used LIA cocktail formulations: Bupivacaine, LB, and Ropivacaine. MethodsBetween 2018 and 2019, 179 consecutive patients underwent reverse total shoulder arthroplasty for end-stage shoulder arthropathy. Patients were enrolled and randomized in a prospective, double-blind clinical trial to receive one of 3 LIA injections before skin incision and after skin closure: 0.25% Bupivacaine ±Epinephrine, 1.3% LB, or 0.5% Ropivacaine cocktail with Ketorolac. There were 67 patients excluded due to preoperative comorbidities or consent refusal. The eligible 112 patients were monitored for 24 hours after surgery. Mean age was 67.9 years (range: 40-90 years). The primary outcome measure was the mean preoperative Visual Analog Scale (VAS) pain score, mean postoperative VAS score during the 24-hour postoperative period, and change in mean VAS score. The secondary outcome measure was total Morphine Milligram Equivalents (MMEs) used, antiemetic use, and laxative use during the same period. Pre-hoc power analysis found a total sample size of 219 (73 per group) was estimated to detect a significant difference at 80% power and 0.05 Type I error rate. ResultsUse of Bupivacaine, LB, and Ropivacaine resulted in 1.2±2.9, 0.6±3.2, and 0.1±2.8 change in VAS scores, respectively (P=.32). Total postoperative MMEs used were 124.1±115.1, 116±84.5, and 105±96.7 milligrams, respectively (P=.71). There were no statistically significant differences amongst the 3 cocktails for postoperative pain relief or rate of antiemetic/laxatives used.There was a nonsignificant trend toward superior analgesic effect of Ropivacaine compared to Bupivacaine. Ad-hoc power analysis found that the estimated sample sizes required to detect a difference between the Ropivacaine and Bupivacaine treatment for change in VAS score and total MMEs use, were 321 and 1593 patients, respectively. Because of the non-clinically significant differences, continued patient enrollment was terminated. The cost of Bupivacaine was comparable to Ropivacaine ($13.43 and $21.95, respectively), whereas LB cost ($434.96) was 20-30 times higher. ConclusionThere were no differences in clinical efficacy amongst Bupivacaine, LB, and Ropivacaine cocktails for perioperative pain management in shoulder arthroplasty. LB was not clinically advantageous compared to the other two medications and did not justify the increase in cost. Level of EvidenceLevel I; Randomized, Controlled Trial

P–348 Laparoscopic radiofrequency thermal ablation for diffuse adenomyosis: symptomatology after a long-term follow-up

Abstract Study question Is conservative laparoscopic treatment with RFA (radiofrequency thermal ablation) related to a good outcome on a long-term follow-up? Summary answer RFA for diffuse adenomyosis was related to a good outcome on a long-term follow-up in terms of pain and ultrasonographic reduction. What is known already Uterine adenomyosis may cause symptoms refractory to medical treatment. New, uterine-sparing treatments have been introduced for patients who desire avoiding hysterectomy. Among surgical techniques used for this purpose, radiofrequency thermal ablation (RFA) has been introduced, first for the treatment of uterine fibroids and then for focal adenomyosis. Diffuse adenomyosis is characterized by an extensive involvement of uterus, as on ultrasound less than 25% of the lesion is surrounded by healthy myometrium. It often leads to enhanced uterine volume, which presents soft consistence and globular aspect. Conservative treatment of diffuse adenomyosis is a real challenge. Study design, size, duration All consecutive patients who underwent RFA for diffuse adenomyosis in our institution between July 2011 and August 2017. Patients with focal adenomyosis were not included in the study. The treatment was reserved to selected patients who wanted to conserve the uterus and presented symptoms such as pain or abnormal uterine bleeding refractory to medical treatment. In all cases the treatment was performed by laparoscopy, which allowed for complete removal of extrauterine endometriosis, if associated. Participants/materials, setting, methods Nineteen patients (aged 33–49, mean 40) underwent radiofrequency thermal ablation for diffuse adenomyosis, and all of them completed the follow-up. Setting: referral center for endometriosis (Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy, Negrar). Follow-up consisted on ambulatory clinical evaluation with pelvic ultrasound and assessment of pain using the visual analog scale (VAS) ranging from 0 to 10 points for all pain components. Main results and the role of chance: Endometriosis was associated in12 cases, (63%) and in all cases was removed completely during surgery. The mean follow-up was 64 months (range 29–105). Abnormal uterine bleeding was present in 11 (60%) patients before the treatment and only in four of them (21%) during the follow-up. Preoperative and postoperative mean VAS score for dysmenorrea, dyspareunia, dyschezia and chronic pelvic pain was 6.95 vs 3.7, 4.1 vs 1.4, 3.7 vs 0.9 and 3.9 vs 1.5 respectively (p &amp;lt; 0.05 for all pain components). The reduction of adenomyosis on ultrasound was observed in 75% of cases. After surgery, two of four patients who desired pregnancy conceived, one of them delivered at term by caesarian section and one had an extrauterine pregnancy. Hysterectomy was performed in two cases during follow-up, at 35 and at 84 months after RFA. Limitations, reasons for caution The present study reports outcome in a limited population as the treatment was reserved to selected cases. The results, particularly regarding fertility and pregnancy outcome should be taken with caution because of small numbers. In our opinion for the moment the treatment should be performed in selected cases. Wider implications of the findings: The present treatment could be performed to avoid hysterectomy, as it was necessary only in two cases in our study. No cases of hysterectomy were reported within the first two years from surgery, so we can consider that RFA allows at least a temporary benefit on symptoms. Trial registration number Not applicable

Thoracolumbar Interfascial Plane Block Results in Opioid-Free Postoperative Recovery After Percutaneous/Endoscopic Transforaminal Lumbar Interbody Fusion Surgery

To evaluate efficacy in reducing postoperative pain and opioid analgesia of a novel interdisciplinary strategy combining preoperative thoracolumbar interfascial plane (TLIP) block and percutaneous/endoscopic transforaminal lumbar interbody fusion surgery and to determine time to first postoperative ambulation and hospital length of stay. In this retrospective review, 42 patients who underwent elective single-level percutaneous/endoscopic transforaminal lumbar interbody fusion surgery between 2015 and 2021 were divided into 2 groups: TLIP group with 17 patients who underwent TLIP block and non-TLIP group with 25 patients. Both groups received the same postoperative analgesia with morphine as patient-controlled rescue medication. Visual analog scale and Oswestry Disability Index scores were evaluated. Statistical evaluation was performed with Student t test. In contrast to the non-TLIP group, in the TLIP group, postoperative mean visual analog scale back score and mean Oswestry Disability Index score significantly decreased from 6.6 to 3.3 (P < 0.01) and 32.8 to 23.6 (P < 0.01), respectively, at hospital discharge. No differences were found between the groups at 1 month. Overall mean follow-up time was 29 ± 18 months (range, 3-78 months). Patients in the non-TLIP group were administered a median postoperative 24-hour morphine dose equivalent of 23 mg (range, 8-31 mg), while patients in the TLIP group did not require opioid analgesia (P < 0.01). Patients in the TLIP group started postoperative ambulation at a median of 4.1 hours (range, 2.5-26 hours) with a median hospital length of stay of 24 hours (range, 20-48 hours) (P= 0.112). TLIP block significantly improves patient outcome at hospital discharge after transforaminal lumbar interbody fusion surgery without postoperative administration of opioids. A prospective study is recommended to confirm our preliminary results.

Percutaneous Endoscopic Interlaminar Discectomy with Modified Sensation-Motion Separation Anesthesia for Beginning Surgeons in the Treatment of L5-S1 Disc Herniation.

PurposeTo compare the clinical effects of local anesthesia (LA), general anesthesia (GA) and modified sensation-motion separation anesthesia (MA) in percutaneous endoscopic interlaminar discectomy (PEID) in the treatment of L5/S1 lumbar disc herniation (LDH) for the purpose of guiding junior surgeons.MethodsEighty-four patients with L5/S1 LDH underwent PEID using three anesthesia methods. Patients in the LA (26), GA (29) and MA (29) groups received a follow-up examination retrospectively. The general parameters, preparation and anesthesia duration, operative duration, recovery time, incidence of complications, ambulation time, length of hospital stay, incidence of severe complications, and reoperation rate were compared, and clinical outcomes were analyzed using a visual analog scale (VAS), the Oswestry Disability Index (ODI), and the Short-Form Health Survey 36 (SF-36).ResultsMA demonstrated obvious advantages over the other two methods with respect to operative duration and resulted in a better intraoperative experience than LA. The patients in the MA group required less time in bed postoperatively and shorter hospital stays than those in the GA group. The mean postoperative VAS, ODI and SF-36 scores were significantly better than the preoperative scores in all groups (P<0.05), but no significant differences in these scores were found among the three groups (P>0.05). Three cases (3/29) of nervous disorder occurred in the GA group. Two patients (one in the GA group (1/29) and one in the LA (1/26) group) underwent revision surgery, with a total recurrence rate of 2.4% (2/84).ConclusionDue to its high safety and good tolerance by patients, MA is a suitable method for spinal surgeons who are inexperienced with PEID in the treatment of L5/S1 disc herniation.

Effectiveness of Combining Internal Sphincterotomy in Patients Undergoing Open Hemorrhoidectomy

Hemorrhoids are one of the most common presentations of the anal canal [1]. Various treatment modalities have been described over the years. However, still hemorrhoidectomy offers the best chances of permanent cure of symptomatic hemorrhoids.[1, 2] The main complication of hemorrhoidectomy is the pain in the first postoperative week which is very uncomfortable to the patient [3]. The main cause of unpleasant post-hemorrhoidectomy pain is due to the spasm of the internal sphincter that is exposed after open hemorrhoidectomy[4, 5, 6]. Internal Sphincterotomy reduces post hemorrhoidectomy pain by abolishing the hypertonicity (spasm/pressure) of the internal anal sphincter and subsequently reduces the related post hemorrhoidectomy complications[7, 8, 9] The main aim of this study was to compare the postoperative pain and other postoperative complications in two groups of patients treated with open hemorrhoidectomy and open hemorrhoidectomy with internal sphincterotomy. In this Randomised-Control-Trial from October 2018 to April 2020, Group-A underwent open-hemorrhoidectomy and Group-B underwent open-hemorrhoidectomy and internal-sphincterotomy. They were analysed for Visual-Analog-Scale (VAS) for postoperative pain at 12 hours, 24 hours, 48 hours, Day 7, Wexner’s Score for fecal incontinence, duration of postoperative hospitalisation, return to work. Mean postoperative VAS of Group-A at 12 hours, 24 hours, 48 hours, Day-7 was 7.30, 5.03, 2.93, 1.47 respectively. For Group-B, postoperative VAS at 12 hours, 24hours, 48 hours, Day-7 was 6.10, 3.83, 2.00, 1.00 respectively. Mean duration of postoperative hospitalisation in Group-A was 3.6 days and Group-B was 2.6 days. Mean Wexner’s Score for fecal incontinence in Group-A was 0.00 and Group-B was 0.20. Mean duration of return to work in Group-A was 17.43 days and Group-B was 10.23 days. Results were analysed and were found to be statistically significant. Patients of Group-B (open hemorrhoidectomy with internal sphincteroto

Spinal Anesthesia Versus General Anesthesia for Elective Lumbar Spine Surgery: A Randomized Clinical Trial

Either general or regional anesthesia can be used for lumbar disk surgery. The common anesthetic technique is general anesthesia (GA). The aim of this study was to compare the intra and postoperative outcomes of spinal anesthesia (SA) with GA in these patients.Seventy-two patients were enrolled in the study. They were randomized into two groups with 37 patients in GA Group and 35 ones in SA Group. The heart rate (HR), mean arterial pressure (MAP), blood loss, surgeons satisfaction with the operating conditions, the severity of postoperative pain based on visual analogue scale (VAS) and analgesic use were recorded.The mean blood loss was significantly less in the SA Group compared to GA Group (p < 0.05). Intraoperative maximum blood pressure and heart rate changes were significantly less in SA Group (p < 0.05). The surgeons satisfaction was significantly more in the SA Group (p < 0.05). The number of patients who used postoperative analgesic as well as postoperative mean VAS was significantly less in SA Group in comparison with GA group (p < 0.05 for both).Our study showed that SA was superior to GA in providing postoperative analgesia and decreasing blood loss while maintained better perioperative hemodynamic stability without increasing adverse side effects.