The Effect of Cannabinoids on Single-level Lumbar Arthrodesis Outcomes in a Rat Model.

BACKGROUND CONTEXT: The opioid epidemic is a public health crisis affecting spine care and pain management. Medical marijuana is a potential non-opioid analgesic yet to be studied in the surgical setting since its effects on bone healing are not fully understood. Studies have demonstrated analgesic and potentially osteoinductive properties of cannabinoids with endocannabinoid receptor expression in bone tissue. PURPOSE: We hypothesize that tetrahydrocannabinol (THC) and cannabidiol (CBD) will not decrease bone healing in spinal fusion. STUDY DESIGN: Seventy-eight adult Sprague-Dawley rats were used for this study. Utilizing allogenic bone grafts (6 donor rats), posterolateral inter-transverse lumbar fusion at the L4-L5 level was performed. The animals were equally divided into four treatment groups, each receiving 0.1ml intraperitoneal injections weekly as follows: placebo (saline), 5mg/kg THC, 5mg/kg CBD, and a combination of 5mg/kg THC and 5mg/kg CBD (Combo). METHODS: Callus tissue was harvested 2- and 8-weeks post-surgery for qPCR assessment to quantify changes in the expression of osteogenic genes. Manual palpation was done to assess the strength of the L4-L5 arthrodesis on all rats. µCT image-based callus analysis and histology were performed. One-way ANOVA followed by post hoc comparisons was performed. RESULTS: µCT demonstrated no significant differences. Treatment groups had slightly increased bone volume and density compared to control. qPCR at two weeks indicated downregulated RANKL/OPG ratios skewing towards osteogenesis in the CBD group, with the THC and CBD+THC groups demonstrating a downward trend (P>0.05). ALPL, BMP4, and SOST were significantly higher in the CBD group, with CTNNB1 and RUNX2 also showing an upregulating trend. The CBD group showed elevation in Col1A1 and MMP13. Data at eight weeks showed ALPL, RUNX2, BMP4, and SOST were downregulated for all treatment groups. In the CBD+THC group, RANK, RANKL, and OPG were downregulated. OPG downregulation reached significance for the THC and CBD+THC group compared to saline. Interestingly, the RANKL/OPG ratio showed upregulation in the CBD and CBD+THC groups. RANKL showed upregulation in the CBD group. At 2 and 8 weeks, the CBD treatment group showed superior histological progression, increasing between time points. CONCLUSION: This study demonstrates that CBD and THC have no adverse effect on bone healing and the rate of spinal fusion in rats. Osteogenic factors were upregulated in the CBD-treated groups at two weeks, which indicates a potential for bone regeneration. In this group, compared to control, the RANKL/OPG ratio at the early healing phase demonstrates the inhibition of osteoclast differentiation, enhancing bone formation. Interestingly, it shows promoted osteoclast differentiation at the later healing phase, enhancing bone remodeling. This aligns with the physiological expectation of a lower ratio in the early phases and a higher ratio in the later remodeling phases. CLINICAL SIGNIFICANCE: CBD and THC showed no inhibitory effects on bone healing in a spinal fusion model. Moreover, histologic and gene expression analysis demonstrated that CBD may, in fact, enhance bone healing. Further research is needed to confirm the safe usage of THC and CBD in the post-operative setting following spinal fusions.

Plastic and elastic biomechanical properties of anterior cruciate ligament autografts.

BACKGROUND: Anterior cruciate ligament (ACL) rupture is a common orthopedic injury, occurring in roughly 68.6 per 100,000 persons annually, with the primary treatment option being ACL reconstruction. However, debate remains about the appropriate graft type for restoring the native biomechanical properties of the knee. Furthermore, plastic graft elongation may promote increased knee laxity and instability without rupture. This study aims to investigate the plastic properties of common ACL-R graft options. METHODS: Patellar tendon (PT), hamstring tendon (HT), and quadriceps tendon (QT) grafts were harvested from 11 cadaveric knees (6 male and 5 female) with a mean age of 71(range 55-81). All grafts were mechanically tested under uniaxial tension until failure to determine each graft's elastic and plastic biomechanical properties. RESULTS: Mechanically, the QT graft was the weakest, exhibiting the lowest failure force and the lowest failure stress (QT < HT, p = 0.032). The PT was the stiffest of the grafts, having a significantly higher stiffness (PT > QT, p = 0.0002) and Young's modulus (PT > QT, p = 0.001; PT > HT, p = 0.041). The HT graft had the highest plastic elongation at 4.01 ± 1.32 mm (HT > PT, p = 0.002). The post-yield behavior of the HT tendon shows increased energy storage capabilities with the highest plastic energy storage (HT > QT, p = 0.012) and the highest toughness (HT > QT, p = 0.032). CONCLUSION: Our study agrees with prior studies indicating that the failure load of all grafts is above the requirements for everyday activities. However, grafts may be susceptible to yielding before failure during daily activities. This may result in the eventual loss of functionality for the neo-ACL, resulting in increased knee laxity and instability.

While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension.

Purpose: This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis. Methods: A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable. Results: Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk. Conclusion: The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy. Level of Evidence: Level IV, systematic review and meta-analysis of Level I-IV studies.

A passive ankle dorsiflexion testing system to assess mechanobiological and structural response to cyclic loading in rat Achilles tendon.

Tendinopathy is thought to be caused by repeated overload of the tendon with insufficient recovery time, leading to an inadequate healing response and incomplete recovery of preinjury material strength and function. The etiology of tendinopathy induced by mechanical load is being explored with a variety of mechanical load scenarios in small animals. This study establishes a testing system that applies passive ankle dorsiflexion to a rat hindlimb, estimates the force applied to the tendon during cyclic loading and enables the assessment of subsequent structural and biological changes. We demonstrated that the system had no drift in the applied angle, and the registered maximum angle and torque inputs and outputs were consistent between tests. We showed that cyclic loading decreased hysteresis and loading and unloading moduli with increasing cycles applied to the tendon. Histology showed gross changes to tendon structure. This work establishes a system for passively loading the rat Achilles tendon in-vivo in a physiological manner, facilitating future studies that will explore how mechanics, structure, and biology are altered by mechanical repetitive loading.

Assessment of Bone Healing: Opportunities to Improve the Standard of Care.

➤ Bone healing is commonly evaluated by clinical examination and serial radiographic evaluation. Physicians should be mindful that personal and cultural differences in pain perception may affect the clinical examination. Radiographic assessment, even with the Radiographic Union Score, is qualitative, with limited interobserver agreement.➤ Physicians may use serial clinical and radiographical examinations to assess bone healing in most patients, but in ambiguous and complicated cases, they may require other methods to provide assistance in decision-making.➤ In complicated instances, clinically available biomarkers, ultrasound, and magnetic resonance imaging may determine initial callus development. Quantitative computed tomography and finite element analysis can estimate bone strength in later callus consolidation phases.➤ As a future direction, quantitative rigidity assessments for bone healing may help patients to return to function earlier by increasing a clinician's confidence in successful progressive healing.

The Tyrosine Kinase Inhibitor Lenvatinib Inhibits Anaplastic Thyroid Carcinoma Growth by Targeting Pericytes in the Tumor Microenvironment.

Background: Anaplastic thyroid carcinoma (ATC) is a rapidly fatal cancer with a median survival of a few months. Enhanced therapeutic options for durable management of ATC will rely on an understanding of genetics and the role of the tumor microenvironment. The prognosis for patients with ATC has not improved despite more detailed scrutiny of underlying tumor genetics. Pericytes in the microenvironment play a key evasive role for thyroid carcinoma (TC) cells. Lenvatinib improves outcomes in patients with radioiodine-refractory well-differentiated TC. In addition to the unclear role of pericytes in ATC, the effect and mechanism of lenvatinib efficacy on ATC have not been sufficiently elucidated. Design: We assessed pericyte enrichment in ATC. We determined the effect of lenvatinib on ATC cell growth cocultured with pericytes and in a xenograft mouse model from human BRAFWT/V600E-ATC-derived cells coimplanted with pericytes. Results: ATC samples were significantly enriched in pericytes compared with normal thyroid samples. BRAFWT/V600E-ATC-derived cells were resistant to lenvatinib treatment shown by a lack of suppression of MAPK and Akt pathways. Moreover, lenvatinib increased CD47 protein (thrombospondin-1 [TSP-1] receptor) levels over time vs. vehicle. TSP-1 levels were downregulated upon lenvatinib at late vs. early time points. Critically, ATC cells, when cocultured with pericytes, showed increased sensitivity to this therapy and ultimately decreased number of cells. The coimplantation in vivo of ATC cells with pericytes increased ATC growth and did not downregulate TSP-1 in the microenvironment in vivo. Conclusions and Implications: Pericytes are enriched in ATC samples. Lenvatinib showed inhibitory effects on BRAFWT/V600E-ATC cells in the presence of pericytes. The presence of pericytes could be crucial for effective lenvatinib treatment in patients with ATC. Degree of pericyte abundance may be an attractive prognostic marker in assessing pharmacotherapeutic options. Effective durable management of ATC will rely on an understanding not only of genetics but also on the role of the tumor microenvironment.

Effect of intraarticular pressure on glenohumeral kinematics during a simulated abduction motion: a cadaveric study.

BACKGROUND: The current understanding of glenohumeral joint stability is defined by active restrictions and passive stabilizers including naturally-occurring negative intraarticular pressure. Cadaveric specimens have been used to evaluate the role of intraarticular pressure on joint stability, although, while the shoulder's negative intraarticular pressure is universally acknowledged, it has been inconsistently accounted for. HYPOTHESIS: During continuous, passive humeral abduction, releasing the native intraarticular pressure increases joint translation, and restoring this pressure decreases joint translations. STUDY DESIGN: Descriptive Laboratory Study. METHODS: A validated shoulder testing system was used to passively abduct the humerus in the scapular plane and measure joint translations for seven (n = 7) cadaveric specimens. The pressure within the glenohumeral joint was measured via a 25-gauge needle during passive abduction of the arm, which was released and subsequently restored. During motion, the rotator cuff muscles were loaded using stepper motors in a force feedback loop and electromagnetic sensors were used to continuously measure the position of the humerus and scapula. Joint translation was defined according to the instant center of rotation of the glenohumeral head according to the recommendations by the International Society of Biomechanics. RESULTS: Area under the translation versus abduction angle curve suggests that releasing the pressure within the capsule results in significantly less posterior translation of the glenohumeral head as compared to intact (85-90˚, p < 0.05). Posterior and superior translations were reduced after 70˚ of abduction when the pressure within the joint was restored. CONCLUSION: With our testing system employing a smooth continuous passive motion, we were able to show that releasing intraarticular pressure does not have a major effect on the path of humeral head motion during glenohumeral abduction. However, both violating the capsule and restoring intraarticular pressure after releasing alter glenohumeral translations. Future studies should study the effect of simultaneous external rotation and abduction on the relationship between joint motion and IAP, especially in higher degrees of abduction. CLINICAL RELEVANCE: Thoroughly simulating the glenohumeral joint environment in the cadaveric setting may strengthen the conclusions that can be translated from this setting to the clinic.

Assessment of the Factors Influencing the Patient's Comprehension of the Informed Consent to Interventional Pain Procedures.

Background: Informed consent is the first step of every medical procedure and is considered a standard of care for patients undergoing medical interventions. Our study seeks to evaluate patients' understanding of the procedure they consented to and the factors affecting the degree of understanding. Methods: In this cross-sectional study, we used an anonymous postprocedural questionnaire to assess our patients' understanding of the procedure being performed and their level of satisfaction. It was conducted between June 2021 and January 2022 on every consenting patient who declined English interpreter services and was undergoing a first elective lumbar epidural steroid injection. Results: The mean age of 201 subjects was 57.3 (23-90) years, with a race distribution of Black (44.3%), White (31.8%), and other races (23.9%). 15.9% of our subjects worked in the medical field. Older age and patients identified as Black and other races had a positive correlation with the propensity to predict a poor understanding of consent. This study failed to demonstrate any difference in understanding of informed consent content between the different subgroups when stratified by assigned sex at birth, level of education, and profession. Patients' expectation from the treatment was classified as desperate (will take any help they can) in 78 patients (38.8%), feeling hopeful (expecting partial improvement in their symptoms) in 52 patients (25.9%), and being optimistic (will obtain full recovery from this injection) in 71 patients (35.3%). 192 patients (95.5%) were very satisfied with the consent process. Seven patients (3.5%) stated that they wanted more information, and 2 patients (1.0%) did not understand the explanation. 180 patients (89.6%) were satisfied with the overall experience, while 21 patients (10.4%) were not. The Wilks test (likelihood-ratio test) resulted in a p value of 0.023 and was deemed statistically significant for a relationship between understanding of consent and the satisfaction of the patient from the procedure. Conclusions: Although patients carry a variable expectation of procedures, most patients in our pain clinic have a high level of satisfaction despite having a poor understanding of the procedure provided via informed consent. Although our patients' level of objective comprehension is low, those with a better understanding of the procedure tend to have a more satisfactory experience.

A Validated Three-Dimensional, Heterogenous Finite Element Model of the Rotator Cuff and The Effects of Collagen Orientation.

Continuum mechanics-based finite element models of the shoulder aim to quantify the mechanical environment of the joint to aid in clinical decision-making for rotator cuff injury and disease. These models allow for the evaluation of the internal loading of the shoulder, which cannot be measured in-vivo. This study uses human cadaveric rotator cuff samples with surface tendon strain estimates, to validate a heterogeneous finite element model of the supraspinatus-infraspinatus complex during various load configurations. The computational model was considered validated when the absolute difference in average maximum principal strain for the articular and bursal sides for each load condition estimated by the model was no greater than 3% compared to that measured in the biomechanical study. The model can predict the strains for varying infraspinatus loads allowing for the study of load sharing between these two tightly coordinated tendons. The future goal is to use the modularity of this validated model to study the initiation and propagation of rotator cuff tear and other rotator cuff pathologies to ultimately improve care for rotator cuff tear patients.

Reliability of Postoperative Radiographies in Ankle Fractures.

BACKGROUND: The accuracy of reduction of ankle fractures using postoperative plain radiographies (x-ray) remains widely controversial. Some authors have demonstrated that postoperative computed tomography (CT) scan can be useful for these patients. In current study, the efficacy of x-rays after fixation of ankle fractures was investigated based on the CT scan findings. METHODS: A total of 73 patients with ankle fractures who were subjected to open reduction internal fixation (ORIF) were enrolled. After surgery, if the reduction was acceptable based on the x-rays according to standard measurements, the patient was referred for CT scanning. Forty four patients were included in the study. Undesirable CT scan findings including malreduction of fragments or articular surfaces, device malpositioning, missed fractures, and undetected intra-articular fragments were documented. RESULTS: Undesirable CT findings were seen in 25 patients (56.8%). CT scan showed acceptable reduction without device malpositioning in 19 patients. The most prevalent findings in CT images were malreduction and device malpositioning in 17 and 16 patients, respectively. There was no abnormal finding in CT imaging of lateral malleolar fractures. In two thirds of the injured syndesmosis, device malpositioning, and malreduction were detected in CT scan. CONCLUSION: Despite acceptable postoperative x-rays, a considerable number of patients with ankle fractures had inappropriate reduction or undesirable findings in their postoperative CT scan. It seems necessary to use CT scan after ORIF of ankle fractures in order to examine the accuracy of reduction. Further validation of postoperative CT scan in ankle fracture surgery should be investigated.

Predictive Factors Associated with Anterolateral Ligament Injury in the Patients with Anterior Cruciate Ligament Tear.

BACKGROUND: The earlier studies did not assess the associated factors of anterolateral ligament injury, comprehensively. We sought to evaluate the independent predictive factors of anterolateral ligament injury in the patients with anterior cruciate ligament tear. Ultrasound scan has an emerging role in the diagnosis of anterolateral ligament injury. MATERIALS AND METHODS: We included 198 patients with anterior cruciate ligament tear in this study. All the patients underwent knee ultrasound scan to diagnose the anterolateral ligament injury. The potential predictive factors of anterolateral ligament injury were compared between the patients with anterolateral ligament injury and the patients with the intact anterolateral ligament. RESULTS: In all the patients, the anterolateral ligament was seen in the tibial and femoral portions using the ultrasound scan. One hundred and ten patients (55.6%) had anterolateral ligament injury and the anterolateral ligament was intact in 88 patients (44.4%). The lateral collateral ligament injury was significantly associated with the anterolateral ligament injury (p < 0.001). In addition, the iliotibial band injury had a significant relationship with the anterolateral ligament injury (p = 0.001). An increased lateral tibial slope was significantly associated with the anterolateral ligament injury (p = 0.031). Furthermore, the bone contusion of the lateral femoral condyle had a significant relationship with the anterolateral ligament injury (p = 0.004). CONCLUSION: The independent predictors of anterolateral ligament injury included the lateral collateral ligament injury, iliotibial band injury, bone contusion of the lateral femoral condyle, and an increased lateral tibial slope.

Autogenous Osteochondral Grafting for Treatment of Knee Osteochondritis Dissecans: A Case Series Study.

BACKGROUND: Although some surgical techniques have been described for the operative treatment of unstable Osteochondritis dissecans (OCD) of the knee, outcomes are variable and are not satisfying totally. The aim of the present study is to evaluate the outcomes of autogenous osteochondral grafting for OCD of the knee. METHODS: In a case series study, from June 2014 to July 2015, 16 patients with stage II-IV OCD (International Cartilage Repair Society (ICRS)) of the femoral condyle were investigated. Surgical intervention considered in cases of stage III (4 cases) and IV (2 cases) and in stage II (10 cases) ones that were nonresponsive to conservative treatment. At the initial and final visits, the IKDC, Lysholm score and Tegner activity scale were evaluated. RESULTS: The mean preoperative IKDC score (53.4) increased significantly following surgery (84.3) (P<0.001). Based on the IKDC grading system, before the operation, the knee status was graded as nearly normal, abnormal, and severely abnormal in 4, 10, and 2 patients, respectively. At final post-surgical follow up, 15 normal and 1 abnormal knee were documented (P<0.001). The mean Lysholm score increased from 44.3 per operatively to 86.3 (P<0.001).Tegner activity score improved from 2.8±1 pre operatively to 5.6±2 (P<0.001). CONCLUSION: Surgical treatment of unstable OCD using autogenous osteochondral graft shows successful outcomes. In addition to reliable fixation, it can enhance healing and convert an uncontained lesion to contained one appropriate for autogenous osteochondral grafting with healthy cartilage.

Outcomes of Ultrasound-Guided Gastrocnemius Injection With Botulinum Toxin for Chronic Plantar Fasciitis.

BACKGROUND: The objective of this study was to determine whether the injection of botulinum toxin A (BTA) in the medial head of the gastrocnemius muscle could yield improvements in function and disability in patients with chronic plantar fasciitis with follow-up 12 months after treatment. METHODS: Thirty-two patients with chronic plantar fasciitis were included in the study and randomly allocated to the BTA and placebo groups. The visual analog scale (VAS) and American Orthopaedic Foot & Ankle Society (AOFAS) scores were used to evaluate pain levels pre- and postinjection as well as function of the foot, respectively. Patients were also asked to rate their treatment satisfaction 1 year after injection. The range of dorsiflexion was measured before and 12 months after the injection. RESULTS: At the 12-month follow-up, the mean VAS decreased from 7.8 to 4 in the placebo group and from 8 to 0.33 in the BTA group. Furthermore, the mean AOFAS scores increased from 48.4 to 65.3 in the placebo group and from 45.5 to 90.6 in the BTA group. The postinjection scores in the BTA group were significantly higher than those in the placebo group (P < .001). Patient satisfaction in the BTA group was higher than that in the placebo group at the 12-month follow-up. CONCLUSION: In patients with chronic plantar fasciitis, the use of BTA had a positive effect on improvement in pain and foot function 1 year after treatment. LEVEL OF EVIDENCE: Level I, prospective randomized controlled trial.

Humeral shaft fracture: a randomized controlled trial of nonoperative versus operative management (plate fixation).

PURPOSE: This randomized controlled trial was conducted to investigate the outcomes of humeral shaft-fracture management with the functional Sarmiento brace (nonoperative) versus open reduction internal fixation (ORIF). METHODS: Sixty humeral shaft-fracture patients with a minimum age of 18 years were randomly assigned into two groups: operative treatment with open reduction-internal fixation (ORIF) or functional brace (Sarmiento). A similar postoperative rehabilitation program was applied for all subjects for the next 12 months. The outcomes of each method were measured in terms of nonunion rate, union time, "quick" Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire scores, and rate of complications, such as malunion, infection, and radial nerve injury. RESULTS: The two groups had similar baseline characteristics, including age, sex, smoking status, and type and mechanism of fracture. The mean union time was about 4.8 weeks shorter in the ORIF group (13.9 weeks in operative group versus 18.7 weeks in nonoperative group), indicating a definite significant superiority (p=0.001) of ORIF management to functional Sarmiento bracing. However, a comparison of quick DASH scores revealed a borderline-significant difference between the groups (p=0.065). Additionally, we found that treatment of humeral shaft fractures using functional bracing was associated with slightly higher risk of nonunion; however this was not significant (p=0.492). CONCLUSION: According to the present findings, there is remarkable superiority of ORIF over functional Sarmiento bracing in the management of patients with humeral shaft fracture.

Sterile Parts of Operating Gown during Lower Limb Joint Replacement Surgery.

BACKGROUND: The prevention of surgical site infection is one of the most concerning issues in operating rooms. Surgical gowns are worn as one of the intraoperative strategies for infection prevention. The present study investigated whether the gowns remained sterile during the surgical procedure. Furthermore, this study examined which parts of the surgical gown were more prone to contamination. METHODS: The sterility of the gowns was investigated during eight total joint arthroplasties all of which were performed by four surgeons. The samples were taken from the arms and frontal part of the sterile gowns pre- and postoperatively. In the anterior surface of the gown, the sampling was initiated at a strip with 50 cm height from the ground followed by the strips with 15 cm distances from caudal to cephalad. Furthermore, the frontal part of the gown was divided into three parts in relation to the operating room table. Finally, the contamination rate was evaluated in each part. A semiquantitative method was used for the analysis of bacterial culture. RESULTS: Before the operation, there were four samples tested positive for bacterial culture (1.06%). All of these samples were taken from the most proximal strip near the neckline. After the surgery, the rate of contamination in the strips on the frontal part of the gown was reported as 3.1% to 53%. Based on the operating table, the contamination rate was 35.9%, 8.9%, and 47.3% in the distal, middle, and proximal parts of the gown, respectively. The contamination rate at the elbow crease was 23%, and at 5 and 10 cm above the creases were 24% and 36%, respectively. CONCLUSION: The high rate of gown contamination during the operation is concerning. However, part of the gown that was in contact with the operating room table remained clean most of the time. More safe strategies should be used for infection prevention in operating rooms.

Unilateral Epidural Blockade for Lower Limb Fracture Surgery: Parasagittal Epidural Versus Midline Epidural Anesthesia.

OBJECTIVE: To compare the efficacy of parasagittal interlaminar (PIL) and midline interlaminar (MIL) approaches for epidural block in patients with lower limb orthopedic surgery. METHODS: This double-blind randomized clinical trial was performed on 40 patients undergoing tibial shaft fracture surgery. In PIL group, an 18-gauge, 3.5 inch, Tuohy needle was placed at the level of L2-3 or L3-4 intervertebral spaces and pushed forward in a posteroanterior (PA) direction vertical to the body surface. After determining the most lateral place for needle arrival in an anteroposterior (AP) view, needle was pushed forward into the epidural space. For the MIL group, needle was pushed forward from the midline interspinous space with the same method. After confirmation of needle position, 1 mL of contrast was injected to confirm the epidural space distribution and then 15 ml lidocaine 2% was injected. The sensory and motor block level, onset, duration, heart rate (HR), mean arterial pressure (MAP), and arterial oxygen saturation (SPO2), and success rate were recorded. RESULTS: Mean patients' baseline characteristics showed no statistically significant difference between the two groups.p>0.05). Outcome measures were statistically different and significantly higher in PIL group (p-values for sensory block level <0.001, motor block level <0.001, duration of sensory block: <0.001 and duration of motor block <0.001 and success rate: <0.001). Hemodynamic variables didn't show statistically significant difference between the two groups (p-values for Systolic pressure: 0.997, diastolic pressure:0.579, MAP:0.585, HR:0.710). CONCLUSION: Epidural anesthesia with parasagittal interlaminar approach provide deep motor block, high sensory level block, and hemodynamic stability. CLINICAL TRIAL REGISTRY: IRCT2017041615515N2.

Diagnostic efficacy of clinical tests for lumbar spinal instability.

BACKGROUND: Although various clinical tests are utilized to assess lumbar spine instability (LSI), few have documented diagnostic efficacy. We assessed the diagnostic efficacy of four clinical and one radiographic test for LSI in patients with degenerative lumbar disease. METHODS: A cohort of 52 patients with pain attributed to lumbar spine stenosis and degenerative spondylolisthesis were prospectively evaluated utilizing dynamic X-rays, the passive lumbar extension (PLE) test, instability catch sign, painful catch sign, and the apprehension sign. The results of these preoperative tests were compared with spinal surgeons' intraoperative documentation of spinal instability considered in this study as the "gold" standard. RESULTS: Intraoperatively, 33 patients demonstrated instability (63.5%) whereas 28 had motion documented on preoperative dynamic radiography. The sensitivity, specificity, positive, and negative predictive value and accuracy of dynamic radiography were 84.8%, 100%, 100%, 79.1%, and 90.4%, respectively. The diagnostic efficiency of PLE was higher than other additional studies - sensitivity 78.8%, specificity 94.7%, positive predictive value 96.3%, negative predictive value 72%, and accuracy rate 84.6%. CONCLUSION: Dynamic radiography was more reliable than any of the clinical tests in diagnosing LSI. Among the latter, PLE had the highest diagnostic value for establishing LSI.

Open Anterior Hip Dislocation in A Child: A Rare Mechanism of Injury.

Traumatic anterior dislocation of the hip is an extremely rare condition in children and open dislocation is even rarer. This isusually caused by high-energy trauma. In the current study, we present a case of an eight-year-old child suffering from an open anterior-inferior dislocation of the right hip concomitant with pelvic ring disruption and an ipsilateral open distal femoral fracture (Salter-Harris type 4, Gustilo type IIIA) caused by a traffic accident. The patient underwent successful emergent open reduction due to the buttonholed femoral head after appropriate irrigation and debridement. Successful recovery was achieved and the patient was discharged after two weeks. After nine months of follow-up, the X-ray images showed slight changes related to the osteonecrosis of the femoral head. Long-term follow-up over a period of six years showed sufficient range of motion. The patient's gait was normal and he was satisfied with the outcome. In addition, slight non-progressive osteonecrotic changes were obvious in the right hip.

Arthroscopic all-inside ramp lesion repair using the posterolateral transseptal portal view.

PURPOSE: The purpose of this study was to evaluate and describe the clinical results and outcomes of a novel method for all-inside suture repair of medial meniscus ramp lesions through posteromedial and posterolateral transseptal portals during anterior cruciate ligament (ACL) reconstruction. Further, this investigation compared the posterolateral view to the notch view for diagnosis and repair. METHODS: Between 2011 and 2014, 166 patients had ramp lesions concomitantly with ACL injury; 128 patients (107 men and 21 women) were enrolled in the study after qualification. All patients underwent repair of the posterior horn ramp lesion of the medial meniscus, using a suture hook device with PDS No. 1 through a posteromedial portal while viewing from the posterolateral transseptal portal during ACL reconstruction, with a minimum of a 2-year follow-up. RESULTS: Patients were followed up for a minimum of 2 years (range 24-47 months). Their average Lysholm score increased from 61.7 ± 3.2 preoperatively to 87.8 ± 3.9 at last follow-up (p < 0.001). Moreover, their average IKDC scores also improved from 53.6 ± 2.1 (pre-op) to 82.1 ± 3.5 (at last follow-up) (p < 0.001). The peroneal nerve and the popliteal neurovascular bundle were not damaged in any of the patients. CONCLUSION: This study provides evidence that the posterolateral transseptal technique protects neurovascular structures. This technique may be used safely and easily for repair of the posterior horn ramp lesion of the medial meniscus during ACL reconstruction. LEVEL OF EVIDENCE: IV.

Diagnostic Efficacy of UBI Scan in Musculoskeletal Infections.

BACKGROUND: Limited recent studies have demonstrated that 99mTc-UBI scan can be a helpful method in precise diagnosis of infection. In the current study, we aimed to investigate the diagnostic efficacy of 99mTc-UBI scan in detection of musculoskeletal infections. METHODS: Fifty patients with suspected musculoskeletal infections (painful THA, TKA, implant and nonunion) were enrolled in this study. After injection of 99mTc-Ubiquicidin 29-41, up to 30 minutes, dynamic imaging was performed every 1 minute. Whole body anterior and posterior images were acquired at 60 and 120 min (5 min/frame). A polygonal region of interest (ROI) was drawn manually around the area of increased accumulation of tracer (lesion) and anatomically similar area on the contralateral side (background) and the lesion to background ratio (LBR) was calculated. Then, patients underwent surgical procedures to assess infection by tissue sampling and histopathologic studies as gold standard. The receiver operating characteristics (ROC) analysis was performed to find a cut-off value for LBR and determining the diagnostic efficacy of UBI scan in musculoskeletal infections. RESULTS: Histopathologic studies revealed infection in 38 patients. The mean LBR was significantly higher in infected patients (2.05 ± 0.41 vs. 1.52 ± 0.22; P < 0.001). ROC analysis showed that a cut-off point of 1.74 for LBR will have 94.7% sensitivity, 83.3% specificity and 92% accuracy for diagnosis of musculoskeletal infections. CONCLUSION: UBI scan is a useful diagnostic tool for evaluation of patients with suspected musculoskeletal infection. However, UBI imaging has some limitations which result in some incorrect diagnoses. It is important to interpret the results of the scan with regard to the clinical findings.