Source Of Persistent Pain Research Articles

Comparison of Outcomes of Cheilectomy with and without Synthetic Hydrogel Interposition (Cartiva®)

Category:Midfoot/Forefoot; OtherIntroduction/Purpose:Cheilectomy and arthrodesis are the primary surgical treatments of hallux rigidus. While cheilectomy preserves limited motion, that motion can be the source of persistent pain that later requires arthrodesis. Cheilectomy with interposition arthroplasty using a synthetic hydrogel implant (Cartiva) has been proposed as an alternative to arthrodesis. Previous studies compared Cartiva to arthrodesis, but Cartiva is really a modification of cheilectomy, meant to improve its results by distracting the bony surfaces of the first MTP joint. This study compared outcomes of cheilectomy with Cartiva to cheilectomy alone.Methods:A retrospective cohort study assessed the results at 1-year minimum follow-up, identifying patients by CPT code for cheilectomy with (28291) and without (28289) Cartiva interposition. There were forty-five patients: 26 in the Cartiva group and 19 in the cheilectomy group. Tabulated data included: age, gender; preoperative, 6-month, and final postoperative total first MTP ranges of motion (ROM); preoperative and final postoperative VAS and SF-36 scores; and reoperation information. Hallux rigidus grade was assessed by Coughlin and Shurnas criteria. First MTP joint space was measured at the medial, midline, and lateral portions of the joint on both AP and lateral radiographs before, immediately following, and at maximum postoperative follow-up (16 month mean). For analysis, medial, midline, and lateral joint measurements were averaged to generate a composite measure of radiographic joint space. Follow-up means were 23 months for all patients, 18 for Cartiva and 28 for cheilectomy.Results:Mean age was 54. Mean preoperative grade was 2.6 for Cartiva and 2.1 for cheilectomy (p=0.037). Mean preoperative ROM was 44°. At 1 year follow-up, ROM was 39° for Cartiva and 47° for cheilectomy (p=0.95). Mean VAS improved from 5.8 to2.0 and 3.0 for Cartiva and cheilectomy, respectively, at final follow-up (p=0.002, p=0.004). Following Cartiva, two week postoperative joint space means increased: AP midline 1.4 to 2.6 mm, AP composite 1.4 to 2.2 mm, and lateral midline 1.3 to 2.7 mm (p<0.001). At final follow-up, joint space measures returned to levels similar to cheilectomy: AP midline 1.3 vs. 1.2 mm, AP composite 1.1 vs. 1.2 mm, and lateral midline 1.6 vs. 1.2 mm (p>0.3). Five patients in each group (22%) underwent revision.Conclusion::Cartiva offers similar intermediate-term ROM preservation and pain relief as cheilectomy in a cohort with higher grade hallux rigidus. Joint distraction gained by synthetic hydrogel interposition subsides with time to levels similar to cheilectomy. Revision surgery for persistent pain is common in both groups.

Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears

Rotator cuff tears are among the most common shoulder injuries and can be a source of persistent pain, disability, and decreased range of motion and strength. Our hypothesis was to conduct a meta-analysis of recently published studies to compare the clinical results of a double-row technique with the results of a single-row technique for different tear sizes. A search was performed in the MEDLINE, EMBASE, and Ovid databases. All randomized and quasi-randomized clinical trials that reported the outcome of single-row repair and double-row repair techniques were included in our meta-analysis. Two subgroups were set according to the tear size. The outcomes were the Constant score, American Shoulder and Elbow Surgeons (ASES) score, UCLA score, re-tear rate, range of motion, and muscle strength. We included 9 studies in this meta-analysis, 5 of which were randomized prospective studies. There was a statistically significant difference in favor of double-row repair for the overall ASES score, re-tear rate, and internal rotation range of motion. In subgroup 2 (tear size > 30 mm in the anteroposterior dimension), double-row techniques produced better outcomes than single-row techniques. There were no statistically significant differences in the overall Constant score, UCLA score, external rotation and forward elevation range of motion, or muscle strength. Double-row rotator cuff repair techniques have a significantly lower re-tear rate, higher ASES score, and greater range of motion of internal rotation compared with single-row repair techniques. Especially in those rotator cuff tears with a size >30 mm, the double-row technique is recommended for repair.

Humeruskopffraktur und Manschette

During the past decade the evaluation of the rotator cuff in the management of proximal humeral fractures has received increasing attention. Different studies have investigated the pathomorphology, prevalence and impact of rotator cuff lesions on the outcome of non-operative or surgical treatment of proximal humeral fractures. Tendon defects, either chronic or trauma related, are observed mainly in the anterosuperior or posterosuperior aspect of the rotator cuff and present as partial- or full-thickness tears. Structural changes of the rotator cuff muscles including atrophy and fatty infiltration in the context of proximal humeral fractures have been inadequately investigated. The prevalence of coexisting rotator cuff pathology varies between 5 and greater than 50% depending on the method of evaluation, the fracture morphology and the age of the patient. The influence of a concomitant rotator cuff tear on the clinical outcome has not been conclusively investigated. However, different studies indicate that some lesions can be a source of persistent pain and functional deficit after conservative or surgical management of proximal humeral fractures. Therefore, a simultaneous repair of the rotator cuff defect during surgical reconstruction of the proximal humerus is indicated.

Clinical Management of Scapulothoracic Bursitis and the Snapping Scapula

Context:Symptomatic scapulothoracic bursitis and crepitus are disorders of the scapulothoracic articulation that are often poorly understood. They can be a source of persistent pain and dysfunction in the active overhead throwing athlete. It is important to distinguish between scapulothoracic bursitis and scapulothoracic crepitus. Scapulothoracic bursitis refers to inflammation of the bursae secondary to trauma or overuse owing to sports activities or work. Scapulothoracic crepitus is defined by a grinding, popping, or thumping sound or sensation secondary to abnormal scapulothoracic motion.Evidence Acquisition:This article presents the causes, diagnosis, and management of these shoulder conditions in a manner that is relevant to clinicians, athletic trainers, and physical therapists, and it reviews relevant studies to determine the consensus on nonoperative treatment, as well as open and arthroscopic surgical treatment.Results:The causes of scapulothoracic bursitis and crepitus include direct or indirect trauma, overuse syndromes, glenohumeral joint dysfunction, osseous abnormalities, muscle atrophy or fibrosis, and idiopathic causes. Scapulothoracic bursitis and crepitus remain primarily clinical diagnoses; however, imaging studies or local injections may also be helpful. The initial treatment of scapulothoracic bursitis and scapulothoracic crepitus should be nonoperative. Surgical treatment options include partial scapulectomy or resection of the superomedial angle of the scapula, open bursal resection, and arthroscopic bursectomy. Despite the lack of agreement among orthopaedic surgeons concerning which procedure is best for treating symptomatic scapulothoracic bursitis and crepitus, most reports have demonstrated good to excellent outcomes in a significantly high percentage of patients.Conclusion:Clearly, the best initial approach to these conditions is a nonoperative treatment plan that combines scapular strengthening, postural reeducation, and core strength endurance. The addition of local modalities, nonsteroidal anti- inflammatory drugs, and localized injections may also be helpful. If an appropriate trial of nonoperative management proves unsuccessful, surgical correction can produce good results.

Involvement of the Lateral Femoral Cutaneous Nerve as Source of Persistent Pain After Total Hip Arthroplasty

This report describes a situation in which the lateral femoral cutaneous (LFC) nerve was the source of incisional pain in a patient after a total hip arthroplasty. The painful scar was denervated by an approach that resected just the posterior branch of the LFC nerve. This was done through an incision near the anterior superior iliac crest, avoiding any potential exposure of the implant. One of the 3 patients reported here had a coexisting meralgia paresthetica that was treated by the same operative approach. The orthopedic surgeon should include the LFC nerve as an origin of persistent pain after total hip arthroplasty.

The Management of Localized Articular Cartilage Lesions of the Humeral Head in the Athlete

Localized articular cartilage lesions of the humeral head can be a source of persistent pain and functional decline in patients who have failed conservative treatment measures. Many are younger, active patients who pose a challenging management decision for surgeons. The goals of treatment should focus on maintaining humeral bone stock, restoring the contour of the articular surface, minimizing soft-tissue disruption, and relieving symptoms. There has been a trend toward humeral resurfacing arthroplasty and away from stemmed components over the past few decades for younger patients potentially requiring future revision surgery. More recently, the HemiCAP resurfacing system (Arthrosurface, Franklin, MA) has been used for localized defects in patients with Hill-Sachs and reverse Hill-Sachs lesions, avascular necrosis, focal chondral defects, and humeral head osteoarthritis. Early, short-term outcome results of the HemiCAP system are encouraging. In this article, we describe our technique for management of localized articular cartilage defects of the humeral head using the HemiCAP resurfacing system.

Operative Treatment of Stress Fractures of the Metatarsals

A common presenting complaint in athletes and nonathletes alike, metatarsal stress fractures may be a source of persistent pain and loss of lower limb use, resulting in loss of recreational and vocational performance. Although most fractures respond to traditional conservative treatments, some may require more aggressive intervention on the part of the treating orthopaedic surgeon. The identification of these particular problem fractures and the search for associated conditions is important for the optimal outcome of these injuries. Attention to surgical technique is important; the options for adjunctive procedures are presented.

Myofascial Trigger Points: Pathophysiology and Treatment with Dry Needling

IntroductionThe aim of this article is to review the possible mechanisms relating to the pathophysiology and treatment of myofascial trigger points with the technique of dry needling.Muscles and myofascial trigger points (MTrP’s) are a major source of persistent pain (Travell 1983). Myofascial pain is often associated with MTrP’s in muscles, tendons and fascia (Sola 1990, Simons 1999). It is characterized by regional muscle pain and described as dull or achy.

Arthroscopic Excision of a Painful Bipartite Patella Fragment

Abstract Bipartite patella, although usually asymptomatic, can become a source of persistent pain following injury. When nonoperative treatments such as physiotherapy and rest fail to produce any resolution in the symptoms, surgery is usually performed. This may include excision of the painful fragment, lateral retinacular release, or detachment of the vastus lateralis insertion, generally performed as open surgical procedures. In the case of vastus lateralis release, however, there has been recent report of statistically better results using an arthroscopic technique. Furthermore, open partial patellectomy has been criticized as being invasive and at times requiring long postoperative rehabilitation. We describe the case of a 26-year-old man who presented with a painful bipartite patella fragment that had not responded symptomatically to nonsurgical treatment. The painful fragment was removed arthroscopically as a day case under a general anesthetic. This was carried out through 3 portals and involved the use of a combination of probe, periosteal elevator, and arthroscopic shaver. Using this technique, we were able to minimize the surgical trauma associated with an open surgical procedure. The early result of this case encourages the use of an arthroscopic technique for partial patellectomy in the surgical treatment of a bipartite patella.

Depression and Somatization as a Source of Persistent Pain

Depression and Somatization as a Source of Persistent Pain

Control of Inflammation

Inflammation about the knee joint may occur after acute trauma or repetitive overuse. Although this inflammatory response is an attempt to repair damaged structures, it can be a source of persistent pain and permanent tissue alteration. Various therapeutic modalities and drugs have been developed to control inflammation that may be deleterious to functional outcome after knee injuries. We review the means available to attempt to achieve this goal and provide basic clinical guidelines for treatment.