Arthroscopic management of unexplained pain following total knee arthroplasty.

INTRODUCTION: Arthrofibrosis develops in 3-10% of knees after total knee arthroplasty (TKA), which may result in pain and restricted range-of-motion. Treatment options include manipulation under anaesthesia, arthroscopic debridement, and quadricepsplasty, but there is little consensus on their efficacy for treatment of unexplained pain after TKA. The purpose of this study was to report the prevalence and characteristics of unexplained pain after TKA as revealed by arthroscopic exploration, and assess the efficacy of arthroscopic procedures to relieve pain. MATERIALS AND METHODS: From a consecutive series of 684 TKAs, 11 patients (1.6%) had unexplained pain at 7-48 months after TKA. Causes of pain remained unidentified after systematic and differential assessment, but arthroscopic exploration revealed fibrotic tissues, which were debrided during the same procedure. Patients were assessed first at 6-61 months and last at 90-148 months, with pain on a visual analog scale (pVAS) and range-of-motion recorded during both assessments, but Oxford Knee Score (OKS) and Forgotten Joint Score (FJS) only during the last assessment. Residual pain was classified as little or no pain (pVAS, 0-1), moderate pain (pVAS, 2-4), and severe pain (pVAS, 5-10). RESULTS: At first follow-up (n = 11) pVAS improved by 4.1 ± 1.1 (p < 0.001), and range-of-motion improved by 5.0° ± 7.1° (p = 0.041). Seven patients (64%) had little or no residual pain, while four (36%) had moderate residual pain. At final follow-up (n = 9) pVAS improved by 3.2 ± 2.9 (p < 0.001), and range-of-motion improved by 4.4° ± 8.5° (p = 0.154). Six patients (67%) had little or no residual pain, while one (11%) had moderate and two (22%) had severe residual pain. CONCLUSION: Arthroscopic exploration revealed that all 11 knees with unexplained pain had fibrotic tissues, the removal of which alleviated pain in only 67%, while moderate to severe pain persisted in 33% which merits further scrutiny.

Why Are Women with Fibromyalgia so Stigmatized?

INTRODUCTION: Many female pain sufferers with medically unexplained pain are at risk of being stigmatized in our Western society. Fibromyalgia is offered as the exemplar condition. AIM: To understand why these women are being stigmatized. METHODS: A review of the recent literature was conducted with a focus on the perceptions of women with a diagnosis of fibromyalgia who have been stigmatized. RESULTS: Three intertwined themes emerged as contributing to their stigmatization: moralizing attitudes, disbelief as to the reality of pain, and pain's invisibility. CONCLUSION: Given how embedded the factors responsible for the stigmatization of women with fibromyalgia in Western society are, the realistic prospects for addressing this issue are poor.

Symptomatic Tarlov cysts are often overlooked: ten reasons why-a narrative review.

PURPOSE: Tarlov cysts (TCs) are dilations of nerve roots arising from pathologically increased hydrostatic pressure (HP) in the spinal canal. There is much controversy regarding whether these cysts are a rare source of pain or often produce symptoms. The aim of this review was to identify the reasons that symptomatic TCs (STCs) are easily overlooked. METHODS: The literature was searched for data regarding pathogenesis and symptomatology. RESULTS: TCs may be overlooked for the following reasons: (1) STCs are considered clinically irrelevant findings; (2) it is assumed that it is clinically difficult to ascertain that TCs are the cause of pain; (3) MRI or electromyography studies only focus on the L1 to S1 nerves; (4) TCs are usually not reported by radiologists; (5) degenerative alterations of the lumbosacral spine are almost always identified as the cause of a patient's pain; (6) it is not generally known that small TCs can be symptomatic; (7) examinations and treatments usually focus on the cysts as an underlying mechanism; however, essentially, increased HP is the main underlying mechanism for producing symptoms. Consequently, STCs may relapse after surgery; (8) bladder, bowel and sphincter dysfunction are not inquired about during history taking. (9) Unexplained pain is often attributed to depression, whereas depression is more likely the consequence of debilitating neuropathic pain. (10) The recognition of STCs is subject to gender bias, confirmation bias and cognitive dissonance and unconscious bias in publishing. CONCLUSION: There are several reasons STCs are underdiagnosed, mostly due to persistent misconceptions and biases. These slides can be retrieved under Electronic Supplementary Material.

Three dimensional gait analysis in patients with symptomatic component mal-rotation after total knee arthroplasty.

PURPOSE: Purpose of the present cohort study was the determination of lower body function and rotation in patients with symptomatic component mal-rotation after total knee arthroplasty using instrumented 3D gait analysis. METHODS: A consecutive series of 12 patients (61.3 years ± 11.4 years) were included suffering under remaining pain or limited range of motion at least six months after total knee arthroplasty. A CT-scan according to the protocol of Berger et al. and instrumented 3D gait analysis were carried out including clinical examination, videotaping, and kinematic analysis using a Plug-in Gait model. Outcome variables were temporospatial parameters as well as kinematics in sagittal and transversal plane. Data for reference group were collected retrospectively and matched by age and gender. RESULTS: Temporospatial parameters of the study group showed decreased velocity, cadence, and step length as well as increased step time. Single limb support was reduced for the affected limb. In sagittal plane, maximum knee flexion during swing phase was reduced for the replaced knee joint. In transverse plane, there was hardly any difference between affected and non-affected limb. Compared to the reference group, both limbs show significant increased internal ankle rotation and external hip rotation. There were significant strong linear correlations between ankle rotation and hip rotation as well as ankle rotation and radiological tibial mal-rotation. CONCLUSIONS: Patients with symptomatic component mal-rotation after total knee arthroplasty showed typically functional deficits. The affected and non-affected limb showed significant increased internal ankle rotation and external hip rotation, while only the affected, replaced knee showed reduced internal knee rotation. Identification of rotational abnormalities of hip and ankle joints seems to be mandatory in TKA to identify the patient group with external hip rotation, internal ankle rotation, and an elevated risk for symptomatic rotational TKA component mal-alignment.

Psychotherapy for Medically Unexplained Pain: A Randomized Clinical Trial Comparing Intensive Short-Term Dynamic Psychotherapy and Cognitive-Behavior Therapy.

BACKGROUND: The efficacy of intensive short-term dynamic psychotherapy (ISTDP) for medically unexplained pain remains open to debate because of a paucity of high-quality studies. OBJECTIVES: This study sought to evaluate ISTDP as a treatment for medically unexplained pain in outpatients by comparing it with the established evidence-based cognitive-behavioral therapy (CBT) in a randomized clinical trial. METHODS: A total of 341 adults with medically unexplained pain were randomly assigned to 16 sessions of individual manualized CBT (N = 164) or ISTDP (N = 177). The groups were assessed at baseline, after 16 weeks of treatment, and at the 3-month follow-up. The primary outcome was perceived pain assessed using the numerical pain rating scale. The secondary outcomes were psychologic distress, depression, and cognitive variables. The cognitive variables included self-efficacy, catastrophizing, and coping strategies. RESULTS: In the intention-to-treat analysis, the ISTDP and CBT groups both showed improvement in the primary outcome after treatment. Pain symptoms in both conditions were significantly reduced. Both ISTDP and CBT groups demonstrated reductions in psychologic distress, depression and catastrophic thinking, and also increases in the use of relaxation as a coping strategy. The CBT group showed an improvement in self-efficacy that was not obtained in the ISTDP group. However, significant differences were not observed in the primary and secondary outcomes at the 3-month follow-up compared with posttreatment. Overall, both treatments were equally effective at the 3-month follow-up. CONCLUSION: Our results suggest that ISTDP may provide an effective alternative therapy for medically unexplained somatic symptoms of pain.

A Randomized Double-Blind Controlled Trial Comparing Davanloo Intensive Short-Term Dynamic Psychotherapy as Internet-Delivered Vs Treatment as Usual for Medically Unexplained Pain: A 6-Month Pilot Study.

BACKGROUND: Research has shown that Intensive Short-Term Dynamic Psychotherapy (ISTDP) can effectively decrease pain intensity and improve quality of life in patients with medically unexplained pain. OBJECTIVE: Understanding that not all patients with medically unexplained pain have access to in-person ISTDP, this study aims to investigate the efficacy of an Internet-delivered ISTDP for individuals with medically unexplained pain using Skype in comparison with treatment as usual. METHOD: In this randomized controlled trial, 100 patients were randomly allocated into Internet-delivered ISTDP (n = 50) and treatment-as- usual (n = 50) groups. Treatment intervention consisted of 16 weekly, hour-long therapy sessions. The primary outcome was perceived pain assessed using the Numeric Pain Rating Scale. The secondary outcome included Depression Anxiety Stress Scale-21, Emotion Regulation Questionnaire, Mindful Attention Awareness Scale, and Quality-of-Life Inventory. Blind assessments were conducted at the baseline, posttreatment, and at a 6-month follow-up. RESULTS: In the intention-to-treat analysis, pain symptoms in the intervention group were significantly reduced (p < 0.001), whereas a reduction was not observed in the treatment as usual group (p = 0.651). Moreover, there were significant decreases in depression, anxiety, and stress, as well as a greater increase in emotion regulation functioning, mindfulness, and quality of life observed in the intervention group 6 months after the treatment compared with the treatment as usual condition. CONCLUSION: The results of this pilot trial demonstrate that 16 weeks of ISTDP delivered by Skype can significantly improve pain intensity and clinical symptoms of medically unexplained pain.

Changes in Bone Density in Metal-Backed and All-Polyethylene Medial Unicompartmental Knee Arthroplasty.

BACKGROUND: Proximal tibial strain in medial unicompartmental knee arthroplasty (UKA) may alter bone mineral density and cause pain. The aims of this retrospective cohort study were to quantify and compare changes in proximal tibial bone mineral density in metal-backed and all-polyethylene medial UKAs, correlating these with outcome, particularly ongoing pain. METHODS: Radiographs of 173 metal-backed and 82 all-polyethylene UKAs were analyzed using digital radiograph densitometry at 0, 1, 2, and 5 years. The mean grayscale of 4 proximal tibial regions was measured and converted to a ratio: the GSRb (grayscale ratio b), where GSRb>1 represents relative medial sclerosis. RESULTS: In both implants, GSRb reduced significantly to 1 year and stabilized with no differences between implants. Subgroup analysis showed less improvement in Oxford Knee Score in patients whose GSRb increased by more than 10% at 1 year (40/255) compared with patients whose GSRb reduced by more than 10% at both 1 years (8.2 vs 15.8, P=.002) and 5 years (9.6 vs 15.8, P=.022). Patients with persistently painful UKAs (17/255) showed no reduction in GSRb at 1 year compared with a 20% reduction in those without pain (P=.05). CONCLUSIONS: Bone mineral density changes under medial UKAs are independent of metal backing. Medial sclerosis appears to be associated with ongoing pain.

Screw Removal Can Resolve Unexplained Anterior Pain Without Recurrence of Shoulder Instability After Open Latarjet Procedures.

BACKGROUND: Anterior shoulder instability can be successfully treated using Latarjet procedures, although a small proportion of patients report unexplained pain. PURPOSE/HYPOTHESIS: The purpose was to report the prevalence and characteristics of patients with unexplained pain without recurrent instability after open Latarjet procedures and to determine whether screw removal can alleviate pain. The hypothesis was that unexplained pain without recurrent instability might be due to soft tissue impingements against the screw heads and that the removal of screws would alleviate or reduce pain. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We retrospectively reviewed the clinical and radiographic records of 461 consecutive shoulders treated by open Latarjet procedures for anterior instability between 2002 and 2014. Unexplained anterior pain was present in 21 shoulders (4.6%) and treated by screw removal at 29 ± 37 months (mean ± SD). Postoperative assessment at >12 months after screw removal included complications, visual analog scale for pain (pVAS), subjective shoulder value, Rowe score, Walch-Duplay score, and ranges of motion. The study cohort comprised the shoulders of 20 patients (9 women, 11 men) aged 25 ± 6 years (median, 25 years; range, 16-34 years) at screw removal and involved the dominant arm in 13 (62%) shoulders. RESULTS: Screw removal alleviated pain completely in 14 shoulders (67%; pVAS improvement, 6.4 ± 1.8; median, 6; range, 3-8) and reduced pain in the remaining 7 (33%; pVAS improvement, 2.4 ± 1.4; median, 2; range, 1-5). At 38 ± 23 months after screw removal, 2 recurrences of instability unrelated to screw removal occurred. The subjective shoulder value was 79% ± 22% (median, 90%; range, 0%-95%); Rowe score, 85 ± 20 (median, 95; range, 30-100); and Walch-Duplay score, 82 ± 19 (median, 85; range, 25-100). Mobility improved in active forward elevation (171°± 14°), external rotation with the elbow at the side (61°± 12°), and external rotation with the arm at 90° of abduction (67°± 13°) and especially in internal rotation, with only 2 shoulders (10%) limited to T12 spine segment. CONCLUSION: The present findings confirm that unexplained anterior pain after Latarjet procedures can be related to the screws used to fix bone blocks, which can safely be alleviated or reduced by screw removal.

Update on unicompartmental knee arthroplasty: Current indications and failure modes.

Despite the excellent success rates of modern implants, unicompartmental knee arthroplasty (UKA) continues to show relatively high failure and revision rates, especially when compared with total knee arthroplasty (TKA).These higher rates of failure and revision are mainly observed during the early (< 5 years) post-operative period and are often due to incorrect indications and/or surgical errors.The correct clinical and radiological indications for UKA have therefore been analysed and correlated as far as possible with the principal mechanisms and timing of failures of UKA. Cite this article: EFORT Open Rev 2018;3:442-448. DOI: 10.1302/2058-5241.3.170060.

Telemedicine vs. in-person delivery of intensive short-term dynamic psychotherapy for patients with medically unexplained pain: A 12-month randomized, controlled trial.

Introduction This study examined the effectiveness of telemedicine in providing psychotherapy to patients with medically unexplained pain (MUP) who may not have access to in-person treatment. The impact of Internet-delivered intensive short-term dynamic psychotherapy (ID-ISTDP) was investigated for MUP via video teleconferencing (Skype™). Methods A randomized, controlled trial of ISTDP, an evidence-based intervention for MUP, was conducted to compare delivery modalities on variations in MUP symptoms. Eighty-one participants with MUP were randomized to either ID-ISTDP ( n = 39) or in-person ISTDP ( n = 42). Outcome variables included the Numeric Pain Rating Scale, Depression Anxiety Stress Scale-21, Emotion Regulation Questionnaire, Mindful Attention Awareness Scale and the Quality of Life Inventory. In addition, exploratory analyses were used to examine acceptability, satisfaction and compliance in both conditions. Participants were assessed prior to intervention, immediately following the intervention, and 12 months after. Results In the intention-to-treat analysis, in-person ISTDP participants had significantly lower pain intensity than ID-ISTDP participants, both immediately following the intervention ( d = 0.97) and at the 12-month follow-up ( d = 0.82). Moreover, there were significant decreases in depression, anxiety and stress as well as a greater increase in emotion regulation functioning, mindfulness and quality of life observed in the in-person ISTDP group at the end of the intervention and 12 months after the treatment when compared to the ID-ISTDP group. Participants rated both treatment conditions as equally credible and satisfying. Conclusion ISTDP seems most effective when delivered in person in treating MUP patients with highly comorbid conditions with benefits maintained over 12 months.

Patients Are Socially Excluded When Their Pain Has No Medical Explanation.

UNLABELLED: This study investigated whether observers socially exclude patients who experience pain that is not medically explained by means of an experimental design. Fifty-nine participants (individuals from the general population) viewed videos of 4 patients, each accompanied by a vignette describing the presence or absence of a medical explanation for their pain. Participants estimated patient's pain, and rated the sympathy felt for and the inclination to help the patient. To measure social exclusion, participants indicated their willingness to interact with the patients in several situations (Social Distance Scale). Furthermore, the participants were invited to select 2 of the 4 patients as confederates to play a game against another duo. When no medical explanation for the pain was provided, participants attributed less pain, reported feeling less sympathy, and were less inclined to help the patients with daily activities. Of particular importance to this study, participants were less willing to interact with patients with medically unexplained pain and selected less often patients with 'medically unexplained' pain than patients with 'medically explained' pain as confederates in the social game. These results are indicative of social exclusion of patients with pain for which there is no clear medical explanation. PERSPECTIVE: Observers socially exclude patients with pain for which there is no clear medical explanation. These findings have important clinical implications. In particular, social exclusion might have detrimental effects on the mental and physical well-being of patients with pain.