Mean Visual Analog Pain Score Research Articles

Metacarpal Fracture Fixation with Intramedullary Screws.

Background: Intramedullary screws (IMS) have become a viable option for metacarpal fracture fixation. To further appraise their utility, this study assessed clinical and patient-reported short- and medium-term outcomes of IMS fixation for extra-articular metacarpal fractures. Methods: A retrospective cohort study was performed in a series of 32 patients (with a total of 37 fractures) who underwent metacarpal fracture fixation over a 42-month period between January 2020 and July 2023. Results: Mean time for return to work was 39.8 days; mean time for return to full function was 88.4 days; total active motion was 250.7° (range: 204.9-270.9); Quick Disabilities of the Arm, Shoulder and Hand score was 2.3 (range: 0-22.7); mean visual analogue pain score was 0.9 out of 10 (range: 0-6) and a single complication was observed. Conclusions: The use of IMS in metacarpal fracture fixation is a practicable surgical option. IMS fixations yields a satisfactory duration for return to function, good postoperative range of movement, modest pain scores and low rates of complications. Level of Evidence: Level IV (Therapeutic).

Efficacy and safety of an anti-infection topical desiccating agent (DEBRICHEM) in hard-to-heal wounds.

A single centre, non-comparative evaluation was undertaken to observe the clinical results achieved when following best practice for the application of Debrichem. The treatment protocol involved use of this debridement product plus standard of care. The sample comprised 21 patients with complex, non-healing wounds of various aetiologies. One patient dropped out of the evaluation for unknown reasons. Wound types were either venous leg ulcers (n=16) or post-traumatic wounds (n=25). The mean wound duration was 22 months (range: 2 weeks-17 years). Over the 4-week follow-up period, there was a decline in the mean percentage of devitalised tissue present on the wounds, reducing from 69% at baseline to 49% at week 4. Most of the devitalised tissue was slough, for which the mean baseline percentage was 63% compared with an endpoint of 49%. Conversely, the mean percentage of granulation tissue increased from 31% at baseline to 51% at week 4. The mean visual analogue pain score reported during application was 4/10, where 0 represents no pain. However, general wound-related pain scores improved during the follow-up period, with no scores above 2 at week 2, compared with five at baseline. The results indicate that Debrichem is a safe and effective method of debridement that requires minimal training and is single use.

Harvest of large fascia lata autograft: Outcomes in 108 patients.

Due to the reclassification of transvaginal mesh as a high-risk device, there has been renewed interest in the use of fascia lata in pelvic floor reconstruction. Here we report our experience in 108 patients who underwent large fascia lata harvest for pelvic organ prolapse (POP) repair. Our primary objective was to highlight the postoperative morbidity of the large fascia lata harvest in patients who underwent POP repair using fascia lata autograft. Surgery involved harvesting a fascia lata graft through a small lateral upper thigh incision and was used for either autologous transvaginal POP repair or autologous sacrocolpopexy. To prevent seroma, a temporary Jackson-Pratt drain was intraoperatively placed and a mild compression wrap was applied to the area for 4-6 weeks postoperatively. Patient demographics were obtained preoperatively, while physical exam findings and postoperative outcomes related to the fascia lata harvest were collected at sequential follow up visits. One-hundred eight patients underwent 111 large fascia lata harvests for either transvaginal or abdominal/robotic POP repair from July 2016 to January 2022. Mean follow-up was 19.6 months (range: 1-65) with 38 patients having 24 months or more of follow-up. Mean Visual Analog Pain (VAP) score was 1 (range: 0-10). Sixteen patients developed asymptomatic thigh bulges, 16 patients developed harvest site seromas (of which 14 resolved), and 59 patients experienced mild, non-bothersome paresthesia near the incision. Large fascia lata harvest offers a robust autograft for transvaginal or transabdominal POP repair with minimal morbidity. Harvest site complications are minor and typically resolve with expectant management. This technique can be safely utilized in patients who desire graft-augmented repair of POP without the use of synthetic mesh, allograft, or xenograft.

Liposomal bupivacaine interscalene blocks demonstrate a greater proportion of total shoulder arthroplasty patients with clinically tolerable pain: a retrospective quality improvement study of 491 patients

ObjectiveTo evaluate the effects of liposomal bupivacaine use for interscalene blocks on postoperative analgesia in total shoulder arthroplasty patients. MethodsDe-identified total or reverse total shoulder arthroplasty patients between 2018 and 2021 were analyzed. Patients were grouped into single shot interscalene block with liposomal bupivacaine (LB) with plain bupivacaine, other block (OB) with other local anesthetics (mepivacaine, ropivacaine, or plain bupivacaine), or no block (NB). The primary outcome was the proportion of patients with clinically tolerable pain scores (mean VAS ≤4) from 0 to 24 ​h in each group. Secondary outcomes included averaged visual analog pain scores (VAS) and opioid consumption measured in morphine milligram equivalents (MMEs) from 0 to 24 ​h. We also analyzed the proportion of patients with clinically tolerable pain, mean VAS, and opioid consumption from 0 to 72 ​h in those patients with at least a 3-day hospital length of stay. ResultsA total of 491 de-identified total shoulder arthroplasty patients, 285 liposomal bupivacaine group (LB), 178 other block group (OB), and 28 no block group (NB), were analyzed. The primary outcome showed a statistically significant different proportion of patients with clinically tolerable pain from 0 to 24 ​h in the LB group (69 ​%) vs. OB group (39 ​%) vs. NB group (11 ​%) (<0.001). Secondary outcomes included statistically significant differences in VAS (LB median ​= ​3.35, OB median ​= ​4.38, NB median ​= ​5.25 (p ​< ​0.001, <0.001)) and total MME opioid consumption (LB median ​= ​40, OB median ​= ​60, NB median ​= ​88 (p ​< ​0.001, 0.001)) between groups from 0 to 24 ​h. For patients who had hospital stays of at least 3 days, a significant association was found with having achieved clinically tolerable pain 0–72 ​h and the LB group (51 ​%) vs. OB group (21 ​%) vs. NB group (11 ​%) (P ​= ​0.006). However, there was no statistical difference in mean VAS or opioid consumption between these groups. ConclusionA greater proportion of total shoulder arthroplasty patients that received liposomal bupivacaine in interscalene block have clinically tolerable pain scores from 0 to 24 ​h, lower VAS, and lower MME consumption in patients following total shoulder arthroplasty. Level of evidenceLevel III – Clinical Study.

Miserable malalignment syndrome associated knee pain: a case for infra-tubercle tibial de-rotation osteotomy using an external fixator

IntroductionMiserable malalignment syndrome is a complex torsional lower limb deformity with limited consensus on surgical treatment. We present the outcome of de-rotation of the tibia alone using an external fixator.MethodsFifteen patients (22 segments) were operated on between 2012 and 2020; 13 presented with anterior knee pain, and two presented with out-toeing. Gait analysis was done in nine patients, and CT scan rotational profile, including tibial tubercle–trochlear groove distance, femoral version, and tibial torsion, were calculated. Kujala knee pain score and visual analogue pain score (VAS) were recorded. All underwent infra-tubercular osteotomy of the tibia and midshaft osteotmy of the fibula and application of a hexapod circular frame to gradually internally rotate the tibia until the foot aligned with the patella.ResultsThere was no preoperative clinical or radiographic evidence for patellar instability, femoral anteversion 30° (21°–54°), and external tibial torsion 50° (37–70). The mean age at surgery was 21 years (12–37) with a mean follow-up of 20 months (9–83). All osteotomies healed, and the frames were removed at a mean of 111 days (80–168). The mean VAS score improved from 8(5–9) to 1(0–4) postoperatively (P < 0.001). The mean Kujala knee pain score increased from 53 (30–75) to 92 (54–100) postoperatively (P < 0.001). The mean preoperative foot progression angle (FPA) was 37° (20°–50°), with 13 postoperatively walking with neutral FPA. One patient walked with symmetrical + 10° and the other with − 5° FPA. All patients reported relief of knee pain and were satisfied with the alignment.ConclusionGradual correction of severe external tibia torsion with a hexapod external fixator and an infra-tubercle tibial osteotomy could provide an optimum method to eliminate knee pain and improve limb alignment in miserable malalignment syndrome.

Analysis of patient factors associated with selection of corticosteroid injection in the freezing phase of idiopathic adhesive capsulitis.

Primary idiopathic adhesive capsulitis (AC) is characterized by shoulder pain and global limitations in range of motion (ROM). The aim of this study was to determine (1) if a spectrum of symptom severity exists during the freezing phase of AC and (2) identify factors associated with patient selection of corticosteroid injection (CSI) for treatment. Patients presenting within 6 months of symptom onset of AC (freezing phase) were enrolled in this single-site retrospective case control study. Visual analog pain scale (VAS) score, shoulder ROM, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores, and Patient-Reported Outcomes Measurement Information System (PROMIS function and pain) scores were collected. Each patient was offered oral anti-inflammatory medication, physical therapy, and intra-articular CSI. Patients were divided into 2 cohorts: those electing vs. those deferring CSI. Multivariable logistic regression was performed to identify patient or symptom characteristics predictive of electing CSI. A total of 112 patients (mean age=54.7 ± 8.8 years, female=76 [67.9%], mean symptom duration =13.2 ± 7.9 weeks, elected CSI=74 [66.1%]) were included in our analysis. The overall study population demonstrated a wide spectrum of VAS pain scores (6.0 ± 2.8, range: 0-10) and ROM: forward elevation (99° ± 27°, range: 30°-150°), abduction (82° ± 24°, range: 30°-130°), external rotation (47° ± 13°, range: 0°-90°), internal rotation (38° ± 26°, range: 5°-90°). The CSI group had higher mean VAS pain score (6.6 ± 2.5 vs. 4.9 ± 3.0, P=.005) and greater limitations in ROM for forward elevation (92° ± 27° vs. 113° ± 25°, P=.001) and abduction (77° ± 24° vs. 90° ± 21°, P=.005) compared with the non-CSI cohort. The CSI group demonstrated significantly worse shoulder function based on Constant (P<.05), ASES (P=.001), P-UE (P=.016), P-Intensity (P=.002), and P-Interference (P=.004). Logistic regression demonstrated decreased total shoulder ROM in forward elevation and abduction plane (OR=0.98, 95% CI=0.97-0.99, P=.004). Hispanic ethnicity and increased VAS pain score (OR=1.20, 95% CI=1.01-1.43, P=.04) were associated with increased likelihood of electing CSI. A spectrum of symptom severity exists during the freezing phase of primary AC, despite similar etiology. AC patients with greater pain severity, and greater limitations in ROM at initial evaluation were associated with patient selection of CSI.

Treatment of distal femur fractures with retrograde intramedullary nailing utilizing a tibial nail

Abstract&#x0D; Aim&#x0D; Retrograde intramedullary nailing for the treatment of femur fractures is a sound option due to its advantages including ease of implant placement and better control of the distal segment, especially in distal femur fractures. Unfortunately, retrograde femoral nails are not available in most developing countries or rural areas. The primary aim of the study is to investigate the outcomes of an alternative treatment of distal femur fracture with retrograde intramedullary nailing using a tibial nail. &#x0D; Material and Method&#x0D; Patients who had distal femur fractures and underwent retrograde intramedullary nailing with a tibial nail between January 2020 – March 2022 are retrospectively evaluated. Patients who were treated other than a tibial nail, aged below 18, had follow-up less than 6 months, multiple fractures, and open fractures were excluded. Patients’ demographics, time to union, and complications were recorded. Functional outcomes included visual analogue pain score (VAS), Lysholm score, Tegner activity scale, Knee Society Score (KSS), and Short Form-36 (SF36) on the latest follow-up.&#x0D; Results&#x0D; A total of 15 patients (11 male, 4 female) met the inclusion criteria and included in the study. The mean age of the patients was 42.9 ± 17.3 (range, 18 to 72) months. The mean follow-up period was 10.1 ± 5.2 (range, 6 to 18). There was no reduction loss and implant failure during follow-ups. One patient had nonunion. No intraoperative fracture occurred. Persistent knee pain was seen in a patient due to an intraarticular screw and removed arthroscopically. In the latest follow-up, the mean VAS was 0.73 ± 0.70 (range, 0 to2), the mean Tegner score was 5.0 ± 1.5 (range, 3 to 7), the mean Lysholm score was 90.9 ± 9.9(range, 64 to 100), the mean KSS was 86.6 ± 8.6 (range, 70 to 97), and the mean SF-36 score was 96.5 ± 4.7 (range, 87 to 100). &#x0D; Conclusion&#x0D; The results of this study suggest that a tibial nail with retrograde intramedullary nailing has good functional outcomes in the treatment of distal femur fractures. The tibial nail should be considered as an alternative treatment option where distal femoral nails are not available.

Augmenting Pathologic Acetabular Bone Loss With Photodynamic Nails to Support Primary Total Hip Arthroplasty.

BackgroundPathologic acetabular defects can undermine the stability and osseointegration of a primary total hip arthroplasty (THA) acetabular component. Our service has used photodynamic nails (PDNs) in a modified Harrington technique to provide space-filling stability to a primary acetabular implant without impeding local osseointegration. Here we describe our experience with PDN-augmented THAs.MethodsAn institutional review board-approved retrospective analysis of all patients who underwent PDN-augmented THA in the management of severe (Harrington class II or III) acetabular defects from September 1, 2020 to May 1, 2021 with at least 6 months of follow-up was performed. The primary outcome was implant survivorship. Comparisons between preoperative and 6-week postoperative visual analogue pain scores were made using the Mann-Whitney U test.ResultsSix patients were included in this case series, 5 with metastatic cancer and 1 with pelvic discontinuity and avascular necrosis following failed attempted acetabular fixation. The mean follow-up duration was 10.3 ± 4.3 months. The mean age was 75.5 ± 4.7 years, mean body mass index 27.3 ± 5.6, and 5 patients were female. All but 1 patient was American Society of Anesthesiologists (ASA) class III. Two patients required acetabular revisions, one for aseptic loosening and a second for a pathologic fracture secondary to disease progression. One patient passed away 90 days after the procedure. The mean visual analogue pain score significantly improved from 7.8 ± 1.6 to 2.0 ± 1.4 six weeks after surgery (P = .008).ConclusionsPDN augmentation of the periacetabular bone of patients with large pelvic defects yields durable pain relief and function in vulnerable hosts. PDN should be considered a part of the reconstructive surgeon’s armamentarium.

Total Autologous Fascia Lata Sacrocolpopexy for Treatment of Pelvic Organ Prolapse: Experience in Thirty-Four Patients

ObjectiveTo develop a technique for open/robotic sacrocolpopexy using autologous fascia lata autograft. We report our experience in our first 34 patients. MethodsThe operation utilizes a 4-5-cm x 15-18-cm piece of fascia lata harvested through a 3-4-inch lateral upper thigh incision. The graft is configured into a traditional Y-shaped configuration using CV-2 Goretex sutures and is used to perform sacrocolpopexy. Patients were followed by history and physical, POP-Q scores, and symptoms related to thigh harvest including visual analog pain (VAP) scores. Treatment failure was defined as symptomatic pelvic organ prolapse (POP) involving apical descent. ResultsAutologous fascia lata sacrocolpopexy was performed on 34 patients with a mean age of 62. Mean follow-up was 13 months (range 2-42). Thirteen cases were open sacrocolpopexies, and 21 were robotic. Concurrent procedures included hysterectomy (9), vaginal mesh excision (7), bowel resection and rectopexy (5), and autologous sling (5). POP symptoms resolved in all 34 patients, and there were no treatment failures. The overwhelming majority of harvest site issues were minor and managed expectantly. Mean VAP score at the harvest site was 0.4 (range 0-3). Three patients developed non-bothersome thigh bulges. One patient developed a harvest site seroma. Twelve patients reported mild, non-bothersome harvest site paresthesias. No thromboembolic events occurred. ConclusionAutologous fascia lata sacrocolpopexy is an efficacious treatment for patients who desire non-mesh POP repair. Most harvest site issues are minor and typically resolve with expectant management alone. Continued follow-up of this series is ongoing to determine long-term success of this operation.

Concomitant septic arthritis of the hip joint and femoral head avascular necrosis in patients with recent COVID-19 infection: a cautionary report

PurposeAt present, concomitant avascular necrosis (AVN) of femoral head and septic arthritis (SA) as a sequel of COVID-19 infection has yet not been documented. By large-scale use of life-saving corticosteroids (CS) in COVID-19 cases, our aim is to warn of the occurrence of hip joint infection in these patients.MethodsWe report a series of five cases in which patients developed septic arthritis concomitant with AVN after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 1695.2 mg. The time period of onset of hip symptoms in our cases from the beginning of the COVID-19 infection was 56 days in the first case, 43 days in the second case, 30 days in the third case, 29 days in the fourth case and 50 days in the last case, with an average time of 41.6 days. All patients underwent surgery depending on the extent of articular cartilage damage by direct anterior approach.ResultsClinical and laboratory symptoms improved significantly in all patients. The mean visual analogue pain score of the patients decreased from 9.4 (9–10) before surgery to 2.8 (1–4) after 1 week of operation.ConclusionIn any patient with the history of COVID-19 infection specially those who have been treated with corticosteroid as one of the medications prescribed during the disease, any joint symptom specially in the hips should draw our attention to the joint infection, and with timely diagnosis and surgery, their hip joint can be saved.

PD44-06 PUDENDAL BLOCK ANALGESIA WITH VAGINAL SURGERY: A RANDOMIZED, DOUBLE-BLIND, PLACEBO CONTROLLED TRIAL

You have accessJournal of UrologyCME1 May 2022PD44-06 PUDENDAL BLOCK ANALGESIA WITH VAGINAL SURGERY: A RANDOMIZED, DOUBLE-BLIND, PLACEBO CONTROLLED TRIAL Emily Slopnick, Graham Chapman, David D. Sheyn, Sarah Sears, Megan Abrams, Kasey M. Roberts, Robert Pollard, and Jeffrey Mangel Emily SlopnickEmily Slopnick More articles by this author , Graham ChapmanGraham Chapman More articles by this author , David D. SheynDavid D. Sheyn More articles by this author , Sarah SearsSarah Sears More articles by this author , Megan AbramsMegan Abrams More articles by this author , Kasey M. RobertsKasey M. Roberts More articles by this author , Robert PollardRobert Pollard More articles by this author , and Jeffrey MangelJeffrey Mangel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002605.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Effective opioid-sparing postoperative analgesia often requires a multimodal approach, which may include regional nerve blocks. The objective of this randomized controlled trial is to determine whether a pudendal nerve block is associated with improved postoperative pain control and decreased opioid consumption compared to a sham injection at the time of vaginal pelvic reconstructive surgery (PRS). METHODS: In this randomized, double-blind, placebo controlled trial, we enrolled women undergoing benign vaginal PRS at a single academic institution. Exclusion criteria included patients with a diagnosis of chronic pelvic pain, inability to receive non-narcotic analgesia, or any concurrent abdominal procedure. Patients were randomized to receive a transvaginal pudendal nerve block (9mL 0.25% bupivacaine + 1mL 40mg/mL triamcinolone) or a sham injection (10mL normal saline) at the conclusion of surgery. The injection syringe was wrapped by pharmacy to blind the surgeon. Postoperatively, all patients received routine care. Primary endpoints were visual analog pain scores (VAS) and postoperative opioid requirement, measured in the post-anesthesia recovery unit (PACU) and on post-operative days (POD) 1 and 4. A power calculation determined 60 patients were required to show a mean difference of 20mm on a 100mm VAS. Opioid administration was standardized as morphine milligram equivalents (MME), and VAS scores were compared with Wilcoxon-Mann-Whitney analysis. RESULTS: We randomized 71 patients: 36 pudendal block and 35 sham injection. The study groups were well matched with no differences in baseline characteristics or type of surgery performed. Pelvic organ prolapse repairs were the most common procedures (n=63, 87.5%). There was no difference in anesthetic dose or operative time between groups. Pain scores were equivalent between groups in the PACU (mean VAS 53.1 block vs 56.4 sham, p=0.517) and on POD 4 (mean VAS 26.7 block vs 35.5 sham, p=0.131). On POD 1, the intervention group did report less pain than the sham group (mean VAS 29.2 vs 42.5, p=0.047). Patients who received a pudendal block took fewer opioid medications than those in the sham group at all time points, but this difference did not meet statistical significance (PACU 5 vs 7.8 MME, POD1 7.5 vs 11.25 MME, POD4 7.5 vs 21.25 MME, all p>0.05). CONCLUSIONS: Pudendal nerve block resulted in decreased pain reported in the immediate postoperative period and less opioid use, though not statistically significant. Pudendal block may be an additional tool for non-narcotic perioperative analgesia with vaginal PRS. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e710 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Emily Slopnick More articles by this author Graham Chapman More articles by this author David D. Sheyn More articles by this author Sarah Sears More articles by this author Megan Abrams More articles by this author Kasey M. Roberts More articles by this author Robert Pollard More articles by this author Jeffrey Mangel More articles by this author Expand All Advertisement PDF DownloadLoading ...

Ureteroscopy under General Anesthesia Versus Spinal Anesthesia: Stone Clearance and Morbidity

Objectives: To compare stone clearance by ureteroscopy carried out under General anesthesia versus Spinal anesthesia for the treatment of ureteric Stone. Place and duration: For two years from Feb 2019 to Feb 2022, in the Urology department of Islam Medical College Sialkot. Methods: Total 42 patients were selected for study. Males were 26, and Females were 16. Age ranges from 20 years to 56 years. All subjects endured ureteroscopic method for ureteric Stone with semi rigid ureteroscope 8/8.4 fr. The two groups of 21 patients equally were formed. Group A were given General Anesthesia and Group B receiving Spinal Anesthesia. The hospital stays, operative Time, clearance of stones, post-operative and intra operative complications were noted. Results: There were 21 patients in both groups, 16 (76.2%) men in group A (general anesthesia), and 18 (85.7%) men in group B (spinal anesthesia). There were 5 (23.8%) women in A group and 3 (14.3%) women in B group. The patients mean age was 34.1 and 37.2 years in groups A and B, correspondingly. The mean size of stone was 0.80 cm in A group and in group B, it was 1.21 cm (p = 0.001). The surgery duration in group A was 40.9 ± 1.30 mints and for group B; 31.4 ± 2.09 minutes (p = 0.031). The mean stay in hospital was 20.8 and 17.4 hours in groups A (range 8 to 48 hours) and B group (range 6 to 24 hours, p = 0.074), correspondingly (p = 0.073). The mean visual-analog pain score was 3.2 in group A and for group B, VAS was 1.7. Conclusion: In this series, ureteroscopy under spinal anesthesia shortened the duration of surgery and hospital stay and did not carry the risk of additional serious complications. Keywords: Ureteroscopy (URS), Ureteric stone, General anesthesia and spinal anesthesia.

Hemiarthroplasty versus open reduction internal fixation for intra-articular distal humerus fractures in older patients.

Intra-articular distal humerus fractures in the older population remain a challenge to fix, due to the comminution of fragments and poor bone stock. Recently Elbow Hemiarthroplasty (EHA) has gained popularity to treat these fractures, however no studies exist comparing EHA to Open Reduction Internal Fixation (ORIF). To compare the clinical outcomes of patients over the age of 60 years treated with ORIF or EHA for multi-fragmentary distal humerus fractures. Thirty-six patients (mean age 73 years) treated surgically for a multi-fragmentary intra-articular distal humeral fracture were followed up for a mean duration of thirty-four months (12-73 months). Eighteen patients were treated with ORIF and eighteen with EHA. The groups were matched for fracture type, demographic characteristics and follow up time. Outcome measures collected included Oxford Elbow Score (OES), Visual Analogue pain Score (VAS), range of motion (ROM), complications, re-operations and radiographic outcomes. The quality of ORIF was judged against set radiographic criteria in order to understand the effect of sub-optimal ORIF technique. No significant clinical difference was found between EHA and ORIF in mean OES (42.5 vs 39.6, p = 0.28), mean VAS (0.5 vs 1.7, p = 0.08) or mean flexion-extension arc (123° vs 112°, p = 0.12). There were significantly more complications associated with ORIF compared to EHA (39% vs 6%, p = 0.04). ORIF executed with satisfactory fixation technique had a comparable complication rate compared to EHA (17% vs 6%, p = 0.6). Two ORIF patients required revision to Total Elbow Arthroplasty (TEA). None of the EHA patients required revision surgery. This study demonstrated similar short-term functional outcomes between EHA and ORIF for the treatment of multi-fragmentary intra-articular distal humeral fractures in patients >60 years of age. Early complications and re-operations were higher in the ORIF group, although this could be related to improper ORIF technique and patient selection.

A Randomised Control Trial Comparing Opioid and Paracetamol for Pain Control after Carpal Tunnel Release.

Background: Opioids are frequently used for pain control after carpal tunnel release (CTR). However, few studies have examined whether the use of opioids is necessary for pain control after CTR. The aim of this study is to compare the effectiveness of codeine versus paracetamol for pain control after CTR. Methods: This is a prospective comparison of consecutive patients' subjective perception of pain after outpatient CTR. Patients were randomised to receive either codeine or paracetamol for pain control after CTR. Visual analogue scale for pain of both groups was compared on the day of surgery and the first three post-operative days (POD) using non-inferiority test. Results: In the codeine group, the mean pain score was 5.2, 4.0, 2.6 and 1.6 on the day of surgery and the first, second and third days after surgery, respectively. In the paracetamol group, the mean VAS score in the same period was 4.3, 3.5, 2.8 and 2.3. There was no significant difference in the mean visual analogue pain scores between the two groups from the day of surgery to the third POD. Conclusions: Paracetamol was as effective as codeine for relieving the pain after outpatient CTR. Our results suggest that the clinicians might avoid unnecessary prescription of the opioid after outpatient CTR. Level of Evidence: Level III (Therapeutic).

COMPARISON OF LOCAL METHYLCOBALAMINE INJECTION VERSUS LOCAL BUPIVACAINE INJECTION FOR THE TREATMENT OF ACUTE HERPETIC NEURALGIA

Objective: To compare the reduction in mean pain score with local Methylcobalamin injection versus local Bupivacaine injection in patients with acute herpetic neuralgia.&#x0D; Study Design: Quasi experimental study.&#x0D; Place and Duration of Study: Dermatology Outpatient Department, Pak Emirates Military Hospital, Rawalpindi, from Jun to Dec 2019.&#x0D; Methodology: Total 100 patients, having pain score more than 3, fulfilling the selection criteria were divided into two groups. Group A was treated with daily subcutaneous injection Bupivacaine, whereas Group B was treated with daily subcutaneous injection Methycobalamin at the site of neuralgia. Patients were followed up for 4 weeks. The pain score was noted. All the data was entered and analyzed on SPSS version 21.&#x0D; Results: In this study mean age of patients in group A was 43.82 ± 15.76 years and in group B was 44.76 ± 16.92 years. The mean visual analogue pain score at 4th week in the group A patients was 1.14 ± 0.32 and in group B was 1.90 ± 0.97. Statistically significant difference was found in group A (local Bupivacaine) with visual analogue score (VAS) at 4th week (pvalue=0.002).&#x0D; Conclusion: The local Bupivacaine injection showed significant reduction in mean pain score than local Methylcobalamin injection in patients with acute herpetic neuralgia.

Indications and outcomes of palliative major amputation in patients with metastatic cancer

BackgroundPatients with stage IV cancer often experience diminished quality of life and pain. Although palliative amputation (PA) can reduce pain, it is infrequently performed because of the morbidity associated with amputation and the limited life expectancy in this population. Here, we describe the indications for PA in patients with stage IV carcinoma or sarcoma and discuss their clinical courses and outcomes. We hypothesized that PA would be associated with reduced pain and improved quality of life in these patients. MethodsWe retrospectively reviewed medical records of all patients who underwent major amputation (proximal to the ankle or wrist) for metastatic sarcoma or carcinoma from January 1995 to April 2021. We excluded patients who underwent amputation for indications other than palliation. Cox proportional hazards regression analysis was used to determine factors associated with survival after PA. ResultsTwenty-six patients underwent PA (11 for carcinoma, 15 for sarcoma). The most common indications for PA were pain (all patients) and fungating tumor (16 patients). PA was the initial surgery in 7 patients. Forequarter amputations were the most common procedure (6 patients). All patients reported reduced pain after PA, with the mean (±standard deviation) visual analog pain score (on a 10-point scale) decreasing from 5.7 ± 2.9 preoperatively to 0.43 ± 1.3 postoperatively (p < 0.001). The mean preoperative ECOG score was 1.9 ± 0.2 compared with 1.3 ± 0.1 postoperatively (p < 0.001). Fourteen patients were fitted for prostheses (6 upper extremity, 8 lower extremity). Two patients had local recurrence, both within 6 months after PA. The mean survival time after PA was 13 ± 12 months, and mean follow-up was 28 ± 29 months. Mean survival time after PA was not significantly different between patients with sarcoma (11 ± 11 months) versus carcinoma (15 ± 14 months) (p = 0.51). Adjuvant chemotherapy was positively associated with survival; no other factors were associated with survival. ConclusionsPA was associated with significantly reduced pain in all patients with stage IV cancer. PA should be considered for those with intractable pain, fungating tumors, or symptoms that diminish quality of life. Level of evidenceLevel III.

Assess the safety and effectiveness of a novel approach during transurethral pneumatic cystolithotripsy in large urinary bladder stone: quasi-clinical trial

To assess the safety and efficacy of using continuous irrigation-modified hysteroscopy during transurethral pneumatic cystolithotripsy for large bladder calculi. A prospective study was carried out from May 2016 until March 2020. All patients with solitary or multiple bladder stones > 2.5cm were subjected to Transurethral pneumatic cystolithotripsy using a modified continuous irrigation hysteroscopy, the stone fragments were removed by Ellik Evacuator, the safety and effectiveness of the procedures were evaluated, stone-free rate (SFR), stone recurrence and stricture urethra disease during follow-up. 55 patients with a mean age of 57.36 (22-82) years were included, the male: female ratio was 4:1, single stone in 74.5% and the mean stone size was 52mm. Lithotripsy time and an operative time were (20.39 ± 3.06 and 32.00 ± 3.57) minutes, respectively. Mean hospital stay was 10 ± 3.6h. This endoscopic technique succeeded with a 100% SFR. During the 22months of follow-up, no urethral stricture or stone recurrence was documented. The mean visual analog pain score (VAS) was 4.2 ± 2.1 and 1.4 ± 0.6, respectively, during and after the operation. The use of the modified hysteroscopy sheath during transurethral pneumatic cystolithotripsy is safe and effective for the management of large urinary bladder stones, an alternative to holmium laser in developing countries when laser equipment is unavailable. Comparable to other transurethral maneuvers, with a decrease in the risk of urethral stricture disease due to the small caliber of the device, as there is no urethral dilatation is required.

Intravenous Magnesium - Lidocaine - Ketorolac Cocktail for Postoperative Opioid Resistant Pain: A Case Series of Novel Rescue Therapy.

Severe postoperative pain is principally managed by opioids. While effective, opioids do not provide adequate relief in many patients and cause many side effects, including antinociceptive tolerance and opioid-induced hyperalgesia. To evaluate if a combination of intravenous Magnesium, Lidocaine, Ketorolac (MLK cocktail) is a useful rescue therapy through synergistic pharmacological mechanisms for acute pain relief. We present the intravenous combination of magnesium, lidocaine, and ketorolac (MLK cocktail) as a possible rescue for opioid insensitive severe post-operative pain. The principal settings were the post-operative care unit (PACU) and the surgical ward. We retrospectively analyzed the electronic medical record and anesthesia documents of 14 patients experiencing severe postoperative pain, >7/10 visual-analogue pain score (VAS), despite receiving at least 8 mg of intravenous morphine milligram equivalents (MME) after arrival in the LAC+USC Medical Center PACU between September 2012 and January 2013. The data reviewed included patients' demographics, disease etiology, surgical procedure, opioids received perioperatively, and visual-analogue pain scores before and after each analgesic received, and after the MLK cocktail. The a priori primary outcome and a posteriori secondary outcome of this study are mean visual-analogue pain score and morphine milligram equivalent dose administered per hour, respectively. The main tool evaluated has been VAS score. In patients who failed to respond to opioid analgesics, administration of the MLK cocktail improved the VAS pain scores immediately from 9.4 ± 1.0 to 3.6 ± 3.5. The MLK cocktail also decreased the MME doses/hour in the immediate 12 hours postoperative period from 12.4 ± 5.6 to 1.1 ± 0.9. In patients experiencing opioid-resistant severe postoperative pain, the magnesium, lidocaine, and ketorolac combination may be an effective nonopioid rescue therapy. Additionally, magnesium, lidocaine, and ketorolac may be utilized in cases complicated by either antinociceptive tolerance or opioid-induced hyperalgesia and can restore opioid responsiveness.

Comparison of Different Dosages and Volumes of Triamcinolone in the Treatment of Stenosing Tenosynovitis: A Prospective, Blinded, Randomized Trial.

Stenosing tenosynovitis is a condition due to a size mismatch between the flexor tendons and the first annular pulley. Corticosteroid injection is the mainstay treatment. The purpose of this study is to compare different dosages and volumes of triamcinolone in the treatment of primary stenosing tenosynovitis. Patients with primary Quinnell grades 1 or 2 stenosing tenosynovitis were recruited in this prospective, blinded, randomized trial. Patients were randomized into 1 of 2 groups. Group A received 0.25 mL of triamcinolone 40 mg/mL, mixed with 0.25 mL of 1% lidocaine with epinephrine (10 mg of triamcinolone, 0.5 mL in total volume). Group B received 0.5 mL of triamcinolone 40 mg/mL, mixed with 0.5 mL of 1% lidocaine with epinephrine (20 mg of triamcinolone, 1 mL in total volume). Patients were assessed by a blinded hand therapist at 2 and 4 weeks, and by a blinded hand surgeon at 6 weeks. The primary outcome was complete symptom resolution at 6 weeks. Both per-protocol and intention-to-treat analyses were performed. One hundred ninety-one patients were recruited from 2009 to 2018. Eighty-two and 77 patients had complete data in group A and B, respectively. There was no difference in success rates in complete symptom resolution at 6 weeks between group A (59.8%) and group B (62.3%). The mean visual analogue pain scores on injection were 4.31 ± 2.11 for group A and 4.30 ± 2.09 for group B. Triamcinolone 10 mg was as effective as 20 mg in the resolution of symptoms of Quinnell grade 1 or 2 stenosing tenosynovitis at 6 weeks.

Liposomal bupivacaine interscalene nerve block in shoulder arthroplasty is not superior to plain bupivacaine: a double-blinded prospective randomized control trial

Interscalene brachial plexus blocks are a common modality used to provide adjunctive pain relief with shoulder replacement surgery. In 2018, the Federal Drug Administration approved the use of liposomal bupivacaine (LB) for such nerve blocks. We sought to evaluate whether this formulation of bupivacaine would provide superior pain relief for shoulder replacement patients over standard bupivacaine alone. Our hypotheses were that in the LB cohort the average postoperative pain score over the first 72 hours would be significantly lower, time to block cessation would be longer, total opioid consumption would be lower, and the average patient satisfaction score regarding their pain management would be higher. A randomized, double-blinded study was designed comparing primary shoulder replacement surgery after an interscalene block with 25 mL of 0.5% plain bupivacaine vs. 133 mg of LB with 7.5 mL of 0.5% and 7.5 mL of 0.25% plain bupivacaine. A total of 104 patients were included in the study, with an equal number in each study arm. Patients' visual analog pain scores (VAPS) were followed for their inpatient stay, first 3 full outpatient days, and at a 3-week follow-up. Use of opioid medication was recorded for the same intervals and converted to morphine milligram equivalents. The time to first opioid rescue was documented, as well as the patients' satisfaction with their pain management at both the 3-day and 3-week intervals. No clinically relevant advantage to the use of LB over plain bupivacaine was found. During the second postoperative day, the mean VAPS was 2.4 with LB vs. 3.3 in the standard cohort (P = .0409). The only other statistically significant finding was a higher VAPS with LB during the third full day home compared with standard bupivacaine (4.0 vs. 2.8, respectively, P = .0197). Both of these differences were less than the minimal clinically important difference of 2 for the VAPS. Analysis of the VAPS for the first and third postoperative days, the first and second full days home, and at 3 weeks revealed no significant difference. Similarly, there was no significant difference in time to first opioid rescue, total morphine milligram equivalent use, and patient satisfaction with pain management. When used for an interscalene block to provide adjunctive pain relief in shoulder replacement surgery, the addition of LB to plain bupivacaine provides no additional clinically important benefit to the patient's pain experience over standard bupivacaine.