Efficacy Comparison Between Interscalene Block with and Without Superficial Cervical Plexus Block for Anesthesia in Clavicle Surgery.

Background: Clavicle fractures account for over one-third of shoulder injuries and up to 3.3% of all fractures in adults. While the majority of these fractures can be managed non-surgically, there are instances where surgical intervention is performed. Regional anesthesia (RA) can be a preferred alternative to general anesthesia (GA) to avoid complications and high costs in this surgery. Moreover, the identification of the most optimal approach for RA remains challenging. Objectives: This study aimed to compare the efficacy of interscalene block (ISB) with and without superficial cervical plexus block (SCPB) as an anesthetic technique for clavicular fracture operation. Methods: This double-blinded, non-inferiority clinical trial was conducted on 120 patients randomly divided into 2 groups: One receiving ISB and the other receiving ISB with SCPB. The primary outcome was defined as the conversion to GA. Various factors were recorded, including surgery duration, nerve block initiation, analgesics required in the postanesthesia care unit (PACU), and sedation during surgery. Pain was evaluated using the Visual Analog Scale (VAS) in PACU. SPSS version 26 was used for statistical analysis, performing descriptive analysis, Student's t-tests, and Mann-Whitney U tests to compare non-parametric variables between the 2 groups. Statistically significant results had a P value of less than 0.05. Results: A total of 120 patients were randomly divided into 2 equal groups, each consisting of 50 males and 10 females. The mean age of intervention and case groups were 37.23 ± 13.30 and 38.43 ± 11.95 years, respectively. After performing statistical tests (Student's t-test and Mann-Whitney U test), there was no significant difference in the initiation time of nerve block, surgery initiation time, surgery duration, the amount of required sedation, VAS scores, and meperidine consumption (P > 0.05). None of the patients in both groups required conversion to GA. Conclusions: The primary goal was achieved in all included cases, and no patients required conversion to GA. The efficacy of ISB is the same whether or not it is combined with a SCPB. Interscalene block is an alternative RA approach for clavicle fractures. Thus, ISB alone is as efficient as when used in combination with SCPB.

A Randomized Double-Blind Prospective Study Comparing the Efficacy of Subperiosteal and Periarticular Injections of a Local Anesthetic for Postoperative Pain Management after Total Knee Arthroplasty.

Objectives: Total knee arthroplasty (TKA) serves as an effective surgical treatment method for advanced osteoarthritis (OA). Nonetheless, it is associated with postoperative pain that can influence patients' functional outcome. This study aimed to compare the analgesic effect of subperiosteal and periarticular injection methods of a special local anesthetic in patients who underwent TKA. Methods: This double-blind prospective clinical study was conducted on patients with advanced knee OA who underwent TKA. Patients were randomly divided into two groups, with a local anesthetic (21 ml) administered either in periarticular (P group) or subperiosteal (S group) forms prior to wound closure. The local anesthetic consisted of lidocaine 2% (15 cc), dexmedetomidine (1 cc), and marcaine 0.5% (5 cc). A study-blinded orthopedic resident recorded postoperative pain levels using a 10-point visual analogue score (VAS) (0 indicating no pain, 10 indicating worst pain) at 6, 12, 24, and 48 hours after surgery. Results: A total of 40 patients (P and S group; n=20 each), consisting of 10 males (mean age=67.4 years old), were included in this study. The intensity of pain in the S group was significantly lower than in the P group 24 hours after surgery (mean VAS scores in the P group: 4±1 vs. the S group: 3.3±0.7, P=0.024). Furthermore, VAS scores at 6, 12, and 48 hours post-surgery were lower in the S group compared to the P group; however, the difference was not statistically significant (P>0.05). Conclusion: Our study indicated that subperiosteal injection of lidocaine, dexmedetomidine, and marcaine is more effective than periarticular injection, providing effective postoperative pain management after TKA.

Synergistic effect of LCI with ESWT on treating patients with mild to moderate CTS: a randomized controlled trial.

BACKGROUND: Applying radial extracorporeal shock wave therapy (R-ESWT) with LCI(local corticosteroid injection) in carpal tunnel syndrome (CTS) management is gaining momentum. The objective is to actualize the topic of this study. METHODS: In this prospective randomized controlled trial, forty patients with mild to moderate CTS are divided into two sham- R-ESWT and R-ESWT groups subject to LCI(local corticosteroid injection). The first group received four sessions of sham-ESWT weekly, which involved sound but no energy; the second group received R-ESWT at equal intervals and were assessed for pain score (VAS score) and symptoms (GSS) baseline, 1st month, 3rd month, and 6th month. RESULTS: A considerable improvement is observed in both groups for pain at (P < 0.05) and symptoms at (P < 0.05) in the 3rd month. The second group revealed more significant symptom improvement at (P < 0.05) in the 6th month. CONCLUSION: The R-ESWT + LCI combined therapy course is the first line of treatment in patients with mild to moderate symptoms and leads to control and reduction of symptoms and the need for surgery, thus a primary concern in CTS treatment with an orthopedist.

The analgesic effect and safety of duloxetine in total knee arthroplasty: A systematic review.

Background: Duloxetine is a serotonin and norepinephrine reuptake inhibitor (SNRI) with clinical efficacy in chronic pain conditions. In this study, we aim to evaluate the analgesic effect and safety of duloxetine in total knee arthroplasty (TKA). Methods: A systematic search was completed on MEDLINE, PsycINFO, and Embase from inception to December 2022 to find relevant articles. We used Cochrane methodology to evaluate the bias of included studies. Investigated outcomes included postoperative pain, opioid consumption, adverse events (AEs), range of motion (ROM), emotional and physical function, patient satisfaction, patient-controlled analgesia (PCA), knee-specific outcomes, wound complications, skin temperature, inflammatory markers, length of stay, and incidence of manipulations. Results: Nine articles involving 942 participants were included in our systematic review. Out of nine papers, eight were randomized clinical trials and one was a retrospective study. The results of these studies indicated the analgesic effect of duloxetine on postoperative pain, which was measured using numeric rating scale and visual analogue scale. Deluxetine was also effective in reducing the morphine requirement and wound complications and enhancing patient satisfaction after surgery. However, the results on ROM, PCA, and knee-specific outcomes were contraventional. Deluxetine was generally safe without serious AEs. The most common AEs included headache, nausea, vomiting, dry mouth, and constipation. Conclusion: Duloxetine may be an effective treatment option for postoperative pain following TKA, but further rigorously designed and well-controlled randomized trials are required.

High Tibial Osteotomy Effects on Subtalar Joint in Patients with Genu Varum.

Background: osteotomy around the knee is one of the most common corrective surgeries for lower limb deformities. The exact relationship between the effects of these surgeries on the ankle joint is unclear.This study aimed to investigate the effect of HTO on the subtalar joint in patients with genu varum. Methods: In the case series study33 patients including 27.2% men and 72.7% womenwith an average age of 41.9, with genu varum who underwent corrective surgery of open wedge high tibial osteotomy were studied. the heel alignment angle was determined before and after surgery in 10-months follow-up based on Saltzman view in conventional radiography. The data were then compared. Results: Average genu varum correction angle was 11.9±1.3°. Heel alignment degree was 5.9±1.3° before HTO surgery, and after the surgery,in final follow-up,it was to 3.4±1.2° valgus, this value was statisticallysignificant(p=0.04). Moreover, there was a significant statistical relationship between average correction of Varus deformity and heel alignment anglechanges (P=0.02, r=0.3). Conclusion: Correcting Varus knee deformity can be effectiveon heel alignment angle in patients undergoing HTO surgery with genu varum. The angle of the subtalar valgus decreases as a result.

Surgical Treatment for Bisphosphonate-related Atypical Femoral Fracture: A Systematic Review.

BACKGROUND: Atypical femoral fractures are the femoral fractures located anywhere between the lesser trochanter and the supracondylar flare of the femur. Long-term bisphosphonates, as the most common preventive and treatment medications for osteoporosis, are thought to have an important role in these fractures. Most of the fractures should be treated surgically, and the complications are considerable. METHODS: We searched Medline, CENTRAL, Embase, and DART on February 26, 2020. One author reviewed and retrieved citations from these four databases for irrelevant and duplicate studies, and two other authors independently extracted data from the studies and rated their quality.Patients with surgical treatment of bisphosphonate-related atypical femoral fracture, according to the American Society for Bone and Mineral Research definition, were included. Animal studies, case reports, studies with high-energy trauma, pathological fracture, or malignancy-related fractures were excluded. RESULTS: In total, 316 patients (348 fractures) were included in this study. Mean age of patients was 70.47 years, and 97.5% of them were female. Duration of using bisphosphonates was 4.04 to 8.8 years, and Alendronate was the most common type. Moreover, 65.27% and 34.72% of the reported fractures were in diaphyseal and subtrochanteric, respectively. Moreover, the most common fixation type was intramedullary. Rate of complication was 17.52%, and the most frequent one was non-union, followed by implant failure. The main limitation of this research was that most of the studies did not have a high level of evidence. CONCLUSION: An increase in the rate of atypical femoral fracture with its challenging management makes it an important issue to be noted by orthopedic surgeons. Based on the results of this study, subtrochanteric fractures might have more complications post-operatively and are suggested to be operated on by more experienced surgeons. It was also found that extra-medullary fixation increases the risk of complications. Future studies on union time, outcomes of different surgical methods, and teriparatide therapy may help shed more light on the surgical management of these fractures.

The Effect of Sagittal Femoral Bowing on the Femoral Component Position in Total Knee Arthroplasty.

In the current study, we investigated that how sagittal femoral bowing can affect the sagittal alignment of the femoral component in total knee arthroplasty (TKA). There were 25 patients underwent TKA. Long leg radiography in lateral view was performed. The sagittal femoral bowing (SFB) and component alignment in relation to the sagittal mechanical axis and distal anterior cortical line (DACL) were measured. Finally, the correlation of component alignment and SFB was examined. Mean SFB was 7±2.7 degrees. The component was in flexion position in relation to mechanical axis and DACL as 8.4±2.9 degrees and 1.7±0.9 degrees, respectively. The flexion alignment of the component was significantly correlated with SFB. Mechanical alignment of the limb in both coronal and sagittal axes should be preserved in TKA. SFB can significantly increased the flexion alignment of the femoral component.

Supracondylar Osteotomy in Valgus Knee: Angle Blade Plate Versus Locking Compression Plate.

BACKGROUND: There are few studies comparing the biomechanical properties of angled blade plate and locking compression plates in supracondylar osteotomy. In the current randomized study, we prospectively compared the clinical and radiological outcomes of supracondylar osteotomy using these two plates. METHODS: Forty patients with valgus knee malalignment were randomly assigned to two equal numbered groups: angled blade plate and locking compression plates. All of the patients underwent medial closing wedge supracondylar osteotomy and were followed for one year. Before and after the operation the valgus angle and mechanical lateral distal femoral angle were compared between groups. Also, the rate of complications were compared. RESULTS: After the operation, the mean valgus angle and mechanical lateral distal femoral angle improved significantly in the two groups (P<0.001). Although, the preoperative amount of the valgus angle and mechanical lateral distal femoral angle were the same, at the last visit the valgus angle (5.4±2.1 versus 3.1±1.8; P=0.032) and mechanical lateral distal femoral angle (87.6±2 versus 89.7±3.2; P=0.041) were significantly lower and higher in the angled blade plate group, respectively. Nonunion occurred in four patients (20%) in the locking compression plates group (P=0.35). CONCLUSION: Based on having a larger valgus angle and mechanical lateral distal femoral angle correction in the angled blade plate group and considerable rate of nonunion in the locking compression plate group, the authors recommend using the angled blade plate for fixation of medial closing wedge supracondylar osteotomy for patients with valgus malalignment. However, more long-term studies are required.

Pseudo-patella baja after total knee arthroplasty.

BACKGROUND: One of the complications of total knee arthroplasty (TKA) which has not yet been directly addressed is pseudo-patella baja (PPB). True patella baja (PB) is present when the length of the patellar tendon becomes shorter. PPB is present when the patella tendon is not shortened, but the level of the joint line is elevated. This study was conducted to assess PPB in TKA. MATERIAL/METHODS: Sixty patients who had had a primary TKA at our center between 1995 and 2005 were included. The average follow-up was 27.5 months. The Knee Society Scoring (KSS), lateral knee x-rays and the Blackburne-Peel index were used for assessments. RESULTS: Out of the 60 patients, 43 (72%) demonstrated no joint line elevation or patellar tendon shortening (group A). Fifteen patients (25%) had joint line elevation (group B), and both PB and PPB were present in 2 (3%) patients (group C). KSS was lower in groups B and C compared with group A, but this difference was not statistically significant. The average range of motion (ROM) in group A was significantly higher compared with either group B or C, and patients in groups B and C showed significantly more severe pain compared with group A (P<0.001). CONCLUSIONS: PPB is not an uncommon finding after TKA and is associated with a statistically significant decrease in ROM and an increase in pain. Furthermore, KSS in the PPB group was less than in patients without PPB, although the difference was not statistically meaningful.