Assessing Preoperative Pain Sensitivity Predicts the Postoperative Analgesic Requirement and Recovery after Total Knee Arthroplasty: A Prospective Study of 178 Patients.

BACKGROUND: The aim of this article is to study the correlation between preoperative pain sensitivity and postoperative pain and analgesic requirements for patients undergoing primary total knee arthroplasty. METHODS: Between December 2018 and April 2019, the pain sensitivity of 178 consecutive patients undergoing primary total knee arthroplasty was assessed preoperatively with a digital algometer. The patients reported the VAS (visual analog scale) score at 3 instances of needle prick (phlebotomy, glucometer blood sugar, intradermal antibiotic test dose), during the range of movements and completed the Depression Anxiety Stress Scale score. Postoperative VAS score, analgesic requirement, and physiotherapy milestones were recorded in all these patients on day 0 to day 4. RESULTS: The average age of the patients was 64.13 years and 69.1% were females. Females had lower mean algometry values (56.12 ± 12.77 [standard deviation]) compared to males (71.09 ± 18.78 [standard deviation]) (P < .001). Higher Depression Anxiety Stress Scale correlated with lower algometry values (P < .001). The postoperative VAS score was 2.54 ± 0.59 on the day of surgery which increased to 3.27 ± 0.69 on day 1 after mobilization (P < .001) and reduced to 1.67 ± 0.62 on day 4. Low algometer score correlated with higher postoperative VAS score (P < .05), increased analgesic requirement, and opioid utilization (P < .001), delay in achieving an optimum range of movements (P < .001) and independent ambulation (P < .001). CONCLUSION: Preoperative assessment of pain sensitivity predicts postoperative analgesic requirements and recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively and prolonged physiotherapy.

The longitudinal anatomy of the long head of the biceps tendon and implications on tenodesis.

PURPOSE: Regarding biceps tenodesis, there are no evidence-based recommendations for the ideal level at which to cut and stabilize the tendon. The purpose of this study is to provide information referencing the tendon for potential clinical applications during biceps tenodesis. METHODS: Forty-three embalmed shoulder specimens were dissected, and markers were placed at four points along each biceps tendon: (1) proximal border of the bicipital groove, (2) distal border of the bicipital groove, (3) proximal edge of the pectoralis major insertion, and (4) musculotendonous junction. Using the origin as the initial point of reference, measurements were made to the four subsequent sites. The humeral length was recorded by measuring the distance between the greater tuberosity and the lateral epicondyle. RESULTS: Measurements were recorded from the origin of the tendon on the supraglenoid tubercle to each established point along its length, and the mean, minimum, and maximum values (cm) were calculated as follows: origin to the proximal bicipital groove [2.8 (1.9, 4.3)], distal bicipital groove [5.2 (3.8, 7.0)], pectoralis major insertion [8.1 (6.3, 10.4)], and musculotendonous junction [13.8 (7.7, 20.3)], and overall humeral length [29.2 (25.2, 32.7)]. An analysis demonstrated a statistically significant overall increase in tendon length at each anatomic site as the overall humeral length increased (p < 0.05). Utilizing the constant and coefficient data from our regression analysis, a predictive formula was calculated based on humeral length. For example, distance from the origin to each anatomic point was determined by a formula [Tendon length at each anatomic landmark, cm = coefficient (humeral length, cm) + constant] for each respective anatomic landmark along the course of the tendon. CONCLUSION: This work will allow surgeons who prefer tenodesis to more accurately re-approximate the appropriate length-tension relationship of the biceps when tenodesing the tendon in a variety of locations. This benefit will potentially result in the most efficient biceps muscle-tendon function and improve the results of biceps surgery. LEVEL OF EVIDENCE: IV.

Intralesional Steroid Injection Versus Extracorporeal Shockwave Therapy in the Treatment of Plantar Fasciitis: A Comparative, Prospective, Case Series Study.

Background This study aimed to compare and evaluate the outcomes of intralesional steroid injections (ultrasound-guided) versus extracorporeal shockwave therapy in the treatment of plantar fasciitis. Methodology Between January 2021 and March 2022, 120 (84 male, 36 female) patients with a confirmed diagnosis of plantar fasciitis were identified. Subjective assessment was done using Mayo Clinical Score, and objective evaluation was done by measuring plantar fascia thickness using ultrasonography. For this study, two groups were made, wherein group A was administered a high dose of extracorporeal shockwave therapy, and group B was administered ultrasound-guided intralesional or local steroid injections. Results Plantar fascia thickness was considerably reduced after therapy in both groups; however, the difference in thickness reduction was not statistically significant between both groups. Mayo Clinic Scores showed statistically significant improvement in pain; however, the difference in pain reduction was not statistically significant between both groups. Conclusions A considerable clinical and radiological improvement was noted in both groups; however, we did not record statistically significant and superior results in either group. Intralesional steroid injections provided faster clinical improvement and better patient compliance.

Possibility of Avoiding Anesthesia in the Reduction of Greenstick and Angulated Forearm and Distal-End Radius Fractures in Children: A Comparative Study.

Introduction Greenstick and angulated forearm bone fractures are the most common fractures in children and invariably require closed reduction under anesthesia. However, pediatric anesthesia is somewhat risky and not always available in developing countries like India. Therefore, this study aimed to evaluate the standard (quality) of closed reduction without anesthesia in children and to determine satisfaction among parents. Materials and methods The present study included 163 children with closed angulated fractures of the distal radius and fracture shafts of both forearm bones, who were treated by closed reduction. One hundred and thirteen were treated without any anesthesia (study group) on an outpatient department (OPD) basis, whereas 50 children of similar age and fracture type underwent reduction with anesthesia (control group). After reduction by both methods check X-ray was done to evaluate the quality of the reduction. Results The average age of the 113 children in the present study was 9.5 years (range: 3.5-16.2 years), of which 82 children had radius or ulna fractures, and 31 had isolated distal radius fractures. In 96.8% of children, ≤10° of residual angulation was achieved. Furthermore, 11 children (12.4%) used paracetamol or ibuprofen for pain control in the study group. Moreover, 97.3% of parents stated that they would like their children to be treated without anesthesia if any fracture occurred again. Conclusions Closed reduction of greenstick angulated forearm and distal-end radius fracture in children in the OPD without anesthesia achieved satisfactory reduction and high parent satisfaction while reducing the risks of pediatric anesthesia and its associated complications.

A Rare Combination of Heptadactyl and Hexadactyl Polydactyly in a Neonate.

Heptadactyly and hexadactyly are rare congenital disorders from the polydactyly family. This type of polydactyly is usually classified into three major groups: preaxial (medial ray), postaxial (lateral ray), and central polydactyly. The most common presentation is both preaxial and postaxial polydactyly. The occurrence of heptadactyly and hexadactyly has been reported but the presence of both in the same infant has not been reported yet. We report the presence of both these abnormalities in the same infant.

The Outcome of Placing the Medial K-wire First and Then the Lateral K-wire in Treating Supracondylar Humerus Fractures in Children Treated by Closed Reduction.

Background Displaced Gartland type III and IV supracondylar fractures are difficult to reduce and invariably require closed pining. After closed reduction, taking the anteroposterior (AP) view does not present any problem but when the elbow is placed in flexion and the limb is rotated internally to take a lateral view, the reduction is invariably lost. However, the reduction stays when the arm is rotated outwards, keeping the medial condyle up. This stimulates the idea of whether the medial pin can be placed first and then the two lateral pins to stabilize the fracture. It is very frustrating for young orthopedic surgeons to see reduction getting lost during internal rotation after first doing lateral pinning. There is no clear guideline on which side should be fixed first. Hypothesis We hypothesized that placing the medial pin first maintains the reduction and facilitates the subsequent placing of lateral pins without the loss of reduction. Materials and methods A total of 170 children with displaced supracondylar humerus fractures were included in the study. A total of 120 children were grouped in the medial wire first group, and 50 were placed in the lateral wire first group, which was the control group. The mean age of the children was 7.5 years (range 2-13 years). The gender ratio (M: F) was 5:3; the left elbow was involved in 68% of the injuries, whereas the right elbow was involved in 32% of the injuries. All 170 children had an extension-type injury, with 91 (53.5%) fractures being Gartland type III and 79 (46.45%) fractures being type IV. Results Results were recorded as per Flynn's criteria. At the end of two years of follow-up, the children in the medial wire first group 117 (97.5%) showed excellent results and three (2.5%) children showed good results, whereas, in the lateral wire first group, 48 (96%) children showed excellent results and two (3.8%) children showed good results. There was a significant difference in the mean surgical time of 20.11±15.43 minutes in the medial wire first group vs 41.23±19.65 minutes in the lateral first group (p = 0.0021). None of the children developed permanent ulnar nerve palsy. Conclusions Placing the medial K-wire first rather than the conventional placing of the lateral wire first helps in maintaining the reduction and allows for the subsequent placement of lateral K-wires without losing the reduction, thus minimizing fixation time and producing good results.

Femoral neck exostosis, a manifestation of cam/pincer combined femoroacetabular impingement.

We present 2 cases of cam/pincer combined femoroacetabular impingement treated arthroscopically with labral debridement, acetabuloplasty, and femoral head recontouring. In both cases there was essentially no evidence of osteoarthritis of the hip. However, in both cases raised exostoses were evident on the anterolateral femoral neck in the region that commonly comes into contact with the acetabular rim. On the basis of 3-dimensional dynamic reconstructions, we surmise that these exostoses are a direct result of linear contact between the femoral neck and acetabular rim. We recommend that the presence of these exostoses be carefully noted by the arthroscopic hip surgeon and that they be a geographic marker of the zone of contact between the head-neck junction and the acetabular rim and a guide for the area of head osteochondroplasty in combination with appropriate treatment of the acetabular rim.

Minimally invasive bone grafting of cysts of the femoral head and acetabulum in femoroacetabular impingement: arthroscopic technique and case presentation.

Femoroacetabular impingement (FAI) has been recently established as a risk factor in the development of osteoarthritis of the hip. Intraosseous cysts are commonly seen on imaging of FAI. In most cases these cysts are incidental and do not require specific treatment at the time of surgical treatment of hip impingement. However, in some cases the cysts may mechanically compromise the acetabular rim or femoral neck. We present a technique for treating such cysts with an all-arthroscopic technique using a commercially available bone graft substitute composed of cancellous bone and demineralized bone matrix placed within an arthroscopic cannula for direct delivery into the cysts. This technique may be of benefit to surgeons treating FAI with an all-arthroscopic technique.

Prevalence and predictors of readmissions among adults with cystic fibrosis in the United States.

INTRODUCTION: Patients with Cystic Fibrosis (CF) have increasing rates of hospitalization. We analyzed the burden and predictors of thirty-day readmission among patients with CF in the U.S. MATERIAL AND METHODS: Nationwide Readmission Database (NRD) 2013 was used to identify adults with CF who were hospitalized. These individuals were followed to determine the prevalence of readmission within thirty days of index discharge. Cox proportional hazard regression was used to identify independent predictors of readmission. RESULTS: There were 14,616 index admissions of adults with CF in 2013. Of these, 2,606 (17.8%) patients were readmitted within 30 days of discharge. Female sex and chronic anemia were independent predictors of readmission. The most common causes of readmission were pulmonary exacerbation (31%), lung transplant complications (5.2%), and septicemia (3.4%). CONCLUSION: Readmissions are frequent among adults with CF and contribute to significant healthcare burden and cost among this population.

Thrombolyic and Vasodilator Treatment in a Patient With Prolonged Retinal Ischemia.

Vasospastic transient monocular vision loss associated with systemic lupus erythematosus and antiphospholipid syndrome is typically short lasting and responsive to vasodilators. Virchow's triad of endothelial dysfunction, arterial stasis, and a hypercoagulable state are factors in systemic lupus erythematosus/antiphospholipid syndrome that may potentially contribute to prolonged retinal hypoperfusion and central retinal artery occlusion. Consequently, rapid intervention to address all components of Virchow's triad may increase the probability of a good outcome. Time of retinal viability should guide the management strategy. We report a systemic lupus erythematosus/antiphospholipid syndrome patient with prolonged monocular blindness coinciding with retinal arterial narrowing and rouleaux formation who responded favorably to sequential use of vasodilators and intravenous thrombolysis, addressing each component of Virchow's triad.

Transforaminal Lumbar Interbody Fusion (TLIF).

Historically, posterior lumbar interbody fusion was performed using a directly posterior procedure (PLIF). Transforaminal lumbar interbody fusion (TLIF) utilizes a more lateral window in order to access the interbody space without excessive dural retraction. Theoretical advantages of TLIF include increased fusion success, more complete foraminal decompression, better correction of deformity, and more effective treatment of discogenic pain. The procedure is done with the following steps:1 and 2. Preoperative planning and patient positioning are important to maximize the efficiency of the procedure. There is a wide variety of instrumentation and technique options; therefore, a systematic approach starting with setup is important.3. The spine is approached through a standard posterior midline incision. It is not necessary to expose the lateral gutters, but the addition of posterolateral fusion is common.4. Pedicle screw placement is undertaken via a standard approach.5. Decompression is initiated with a laminectomy in the midline, exposing the ligamentum.6. The ligamentum is carefully removed, and hemostasis is obtained. A facetectomy is then performed.7. Once the posterior bone elements are resected and the decompression is complete, the dura and neural elements are mobilized. The goal is to be able to access the posterior anulus and disc space easily without any dural tension.8. Distraction through the TLIF level helps facilitate interbody placement. We describe a triple distraction technique that uses the midline elements, and both contralateral and ipsilateral distraction methods.9. A window is formed on the disc, with care taken to protect the exiting and traversing roots. The window is enlarged using a combination of box osteotomes and Kerrison rongeurs. A window that is a minimum of 10 mm in size facilitates disc space preparation.10 and 11. Disc space preparation is performed using a combination of curets, pituitary rongeurs, and end-plate preparation tools. Thorough disc-space preparation is critical for both correcting the deformity and obtaining a solid fusion.12. The disc space is sized for an appropriate interbody cage. The anterior aspect of the disc space and the cage are both packed with bone graft. This may involve the use of iliac crest graft, local bone, or bone substitutes, depending on the specific clinical situation.13. Cage and screw placement is verified by biplane radiography, and lordosis is restored by compression across the screws bilaterally. Osteotomy of the contralateral facet may be necessary to achieve substantial restoration of lordosis.14. If the lateral gutters have been exposed, grafting in this region is undertaken as well. Care must be taken with graft placement on the TLIF side as facet and pars resection leaves the exiting route exposed.15. Closure is undertaken in a standard fashion.Postoperative recovery does not differ substantially from other standard fusion procedures. Mobilization is undertaken over the first several weeks, and fusion healing is expected in the 6-month to 1-year time frame.

Extensive Deep Venous Thrombosis Resulting from Anterior Lumbar Spine Surgery in a Patient with Iliac Vein Compression Syndrome: A Case Report and Literature Review.

Study Design Case report. Objective Although May-Thurner syndrome or iliac vein compression syndrome is covered in the vascular literature, it remains absent from the orthopedic and neurosurgery literature and has not been previously reported to occur in concordance with spine surgery. We review the salient points of disease presentation, diagnosis, and treatment. Methods A 33-year-old woman was followed postoperatively via clinical and radiographic findings. Her presentation, operative treatment, postoperative extensive deep venous thrombosis (DVT) formation, and management are described. Results We present a unique case of a healthy 33-year-old woman who developed an extensive left iliac vein DVT after anterior lumbar spine fusion. Although she had multiple risk factors for thrombosis, the size of the thrombus was atypical. A subsequent venogram showed compression of the left common iliac vein by the right common iliac artery, consistent with May-Thurner syndrome. Conclusions May-Thurner syndrome or iliac vein compression syndrome is a rare diagnosis that is absent from the spine literature. The condition can predispose patients to extensive iliac vein DVT. The contributing anatomy and subsequent clot often require catheter-directed thrombolysis and stenting to achieve a favorable outcome.

MRI and MR tractography in bilateral hypertrophic olivary degeneration.

Hypertrophic olivary degeneration is a trans-synaptic neuronal degeneration associated with hypertrophy of the inferior olivary nucleus due to a lesion in the triangle of Guillain-Mollaret. Familiarity with this entity on magnetic resonance imaging (MRI) is essential to avoid other erroneous ominous diagnoses. We present a case of bilateral hypertrophic olivary degeneration and discuss the etiopathogenesis and MRI findings in this entity. The contributory role of MR tractography in the diagnosis is also highlighted.

Adolescent Segond fracture with an intact anterior cruciate ligament.

Segond fractures, or avulsion fractures of the proximal lateral tibial plateau, have been well documented and studied since their original description in 1878. Segond fractures have a widely recognized pathognomonic association with anterior cruciate ligament (ACL) injuries and often prompt orthopedic surgeons to consider reconstruction following radiographic and clinical evaluation. Adolescent patients are particularly vulnerable to these fractures due to the relative weakness of their physeal growth plates compared with the strength of their accompanying ligamentous structures. This article describes a case of a 13-year-old boy who sustained a Segond fracture that was not coupled with an ACL avulsion or tear. The patient sustained a twisting injury to his knee. He presented to the emergency room with an effusion and radiographic findings consistent with a Segond fracture. On follow-up examination 1 week after injury, the ACL was intact. The patient was followed for 5 months of conservative treatment. At final follow-up, the patient had reestablished his previous level of activity. This article describes the history, physical examination, and radiographic findings necessary to care for patients who present with a Segond fracture. Although considered pathognomonic for an associated ACL injury, this article describes a Segond fracture that occurred in isolation.

A complex injury of the distal ulnar physis: a case report and brief review of the literature.

Physeal fractures of the distal forearm are common injuries in children and adolescents. However, Salter-Harris type III and type IV fractures of the distal ulnar epiphysis are often high-energy injuries that require open reduction for restoration of anatomical alignment. These injuries are uncommon and there are few descriptions of them in the contemporary literature. Here we report the case of a 13-year-old boy with a type IV distal ulna fracture not diagnosed with standard radiography. After closed manipulation, an incompletely reduced physis was suspected on the basis of fluoroscopic imaging and comparison radiographs of the contralateral wrist. Computed tomography showed a large, displaced physeal fragment. The patient underwent open reduction and internal fixation. Thorough radiographic assessment should be conducted when there is a high suspicion for these fracture patterns. Appropriate diagnosis can lead to expedient reduction and expectant management of sequelae associated with these injuries.