Anterior Ankle Arthroscopy: Advantage of a Preoperative Ultrasound Mapping to Prevent Neurovascular Complications.

PURPOSE: The aim of this study is to verify the usefulness of ultrasound-assisted mapping of the vascular and neurological structures in the anterior compartment of the ankle just before an anterior arthroscopic procedure to reduce these kinds of complications. METHODS: Various complications can be present in anterior arthroscopy of the ankle. The structures most prone to iatrogenic damage are vessels and nerves. They are macroscopically visible and palpable in a little more than 50% of cases, but arterial ramifications are not visible because they are located deeper. RESULTS: The authors have investigated how to reduce potential iatrogenic damage to the complex and variable neuro-vascular network of the anterior aspect of the ankle. They have completed the classic routine marking of the bony and tendinous structures with an ultrasound mapping of the neurovascular structures. CONCLUSIONS: The authors concluded that ultrasound-assisted mapping is a non-invasive, fast, and safe procedure that can help to reduce potential iatrogenic damage when performing anterior arthroscopic surgery.

Cadaveric Model Simulations for Training in Ultrasound-Guided Percutaneous Placement of a Novel Peripheral Nerve Stimulation Electrode.

Peripheral nerve stimulation (PNS) electrodes are used to treat intractable painful conditions involving peripheral nerves. Methods for performing PNS continue to evolve, from open surgical to minimally invasive placement of electrodes. A PNS system consisting of subcutaneously implanted leads with an integrated anchor and electrodes, and an external pulse generator to produce peripheral neuromodulation, is now available for use in the clinical setting. This novel system allows either surgical or percutaneous lead positioning, and avoids the use of long leads or extensions crossing the joints, which are exposed to mechanical stress and damage. To identify methods for successfully inserting these electrodes, we investigated if a cadaver model could be an effective educational tool for teaching PNS electrode placement using ultrasound guidance. Six cadavers were studied in an attempt to find an ideal approach for ultrasound-guided electrode placement into the upper and lower extremities and cervical spine, and to describe the unique anatomy of the peripheral nerves relative to percutaneous stimulation-electrode placement. The use of cadaveric model simulations offers opportunities to practice percutaneous placement of PNS electrodes under stress-free conditions without patient discomfort, to acquire skill and confidence in performing these surgical approaches. Ultrasound-guided percutaneous placement of PNS electrodes should be learned in a simulation laboratory before such placement is performed in actual patients.

Pain reduction induced by tapentadol in patients with musculoskeletal chronic pain fosters better sleep quality.

BACKGROUND: Poor sleep may predict the increase and intensification of pain over time with increased insomnia symptoms being both a predictor and an indicator of worse pain outcomes and physical functioning status over time. However, the impact of different analgesic therapies on quality of life, functional recovery and sleep has been poorly assessed to date, whereas these evaluations may greatly help clinicians in the selection of treatment when dealing with patients with chronic pain (CP). METHODS: To explore whether tapentadol-induced pain relief may drive improved sleep quality, we carried out a pooled analysis of real-world data collected from 487 patients with CP (mean age, 68.3 years; 57.7% women) suffering from a wide range of chronic musculoskeletal pain conditions and treated with tapentadol. RESULTS: Following tapentadol treatment, patients experienced an 80% reduction in the frequency of very disturbed sleep as well as a 50% reduction in the predominant sleep complaint reported by patients with CP - that is, nocturnal awakenings. A significantly greater proportion of patients reported good/restful sleep at the end of the study period compared to baseline (72.4% versus 25.3%; p<0.01). This benefit was observed regardless of the clinical setting, treatment duration, posology or patient age and was associated with a higher proportion of patients reporting an improved global health status and good tolerability. CONCLUSION: The reduction in pain intensity provided by tapentadol fosters sleep quality and favours a better quality of life. Therefore, our findings provide the rationale for addressing sleep quality as a relevant outcome, complementary to pain relief in CP management.

Sonographic Guidance for Caudal Epidural Steroid Injection: A Diagnostic Tool.

Ultrasound (US)-guided caudal epidural injection is a method of drug administration into the epidural space through the sacral hiatus for both chronic pain management and perioperative analgesia. Here, we describe the usefulness of US sacral examination performed before a caudal epidural injection procedure, in which the results revealed a sacrococcygeal ligament ossification prompting us to avoid its puncture by placing the Thouy needle in the appropriate direction. This prevented an unwanted calcification rupture with a possible drag of material into the sacral canal. US has already been used as a diagnostic tool in caudal epidural injection, mainly to detect the agenesis of sacral hiatus or to measure its diameter. Our case underlines the possibility of finding ossification and calcification using US, which can make the injection difficult or impossible and be a side effect if not recognised.

Prolotherapy: Regenerative Medicine for Lateral Epicondylitis.

Lateral epicondylitis (LE) is a degenerative disease of the tendons, spurred by repetitive microtrauma leading to an attempt by the body to heal by upregulating local angiogenesis and fibroblast proliferation. Prolotherapy (PT) is the injection of dextrose around the injured tissues to stimulate their spontaneous regeneration. Herein, we have described a case of lateral epicondylitis, diagnosed with clinical and ultrasound (US) examination, where local steroid injections provided relief only for a limited time. We treated the patient with US-guided PT, following which the pain disappeared and the tendon was restored.

Anesthesia Experience for Open Gastrostomy with Ultrasound-Guided Erector Spinae Plane Block: A Case Report.

From the first description in 2016 till today, hundreds of studies have extensively presented Erector Spinae Plane block as an excellent perioperative analgesic technique especially in a multimodal pain management scenario. Only in few cases, this technique was used alone to provide surgical anesthesia.

Safety and efficacy of Staged Extubation Set in patients with difficult airway: a prospective multicenter study.

BACKGROUND: A safe extubation is the extension of any airway management strategy. Despite different guidelines, a number of extubation accidents still occurs. Re-intubation failure could be fatal, thus a strategy and safe and efficient devices for this purpose are essential. METHODS: Multicentric prospective observational study on adult patients with endotracheal intubation and known difficult airway. A Staged Extubation Set® (SES) was used for extubation. Demographics, ASA, El Ganzouri, type of surgery, re-intubation success/failure and complications were recorded. The aim of the study was the assessment of the rate of re intubation failure, complications during failures, patients' comfort and evidence of airway injury. RESULTS: Overall, 114 subsequent difficult airway patients were enrolled. Fifteen patients (13%) required re-intubation: ten of 15 (66%) were successfully re-intubated, with a first-pass success rate of 100%. In five patients (33%), re-intubation over SES was unsuccessful, with re-intubation difficulty rate three (easy), three (quite easy) and nine (very difficult) and five cases of desaturation. Complications included one case of esophageal intubation, one case of lip trauma, and two cases of airway edema. Of 114 patients, eight (7%) perceived the procedure as intolerable. CONCLUSIONS: The results from this study show a relatively satisfactory success rate with a relatively high number of re-intubations failure and a low incidence of complications when using a SES in a cohort of difficult airway patients, all failures due to guidewire dislodgement during or after extubation. Further research is needed to improve success rate; at the same time the need for an extubation protocol is strongly advocated.