Intraoperative Surgeon-Performed versus Conventional Anesthesiologist-Performed Continuous Adductor Canal Block in Total Knee Arthroplasty: A Randomized Controlled Trial.

A continuous adductor canal block (cACB) for pain control in total knee arthroplasty (TKA) is always performed by an anesthesiologist. A surgeon-performed cACB during surgery is somewhat questionable in terms of feasibility, reproducibility, and efficacy. This study was divided into two phases. In Phase 1 study, an experimental dissection of 16 cadaveric knees to expose the saphenous nerve and related muscles around the adductor canal was conducted. The extent of dye after injection via a catheter inserted into the adductor canal at the time of TKA was evaluated. In Phase II, a randomized controlled trial study comparing clinical outcomes between surgeon-performed (Group 1) and anesthesiologist-performed cACB (Group 2) during TKA in 63 patients was evaluated. The visual analogue scale (VAS) at rest and during movement at several time points and functional outcomes during hospitalization were compared. The Phase I study demonstrated surgeon-performed cACB during surgery feasible and reproducible with consistent dye extension into the adductor canal after injection via a catheter. In the Phase II study, 29 patients of Group 1 and 30 patients of Group 2 completed the evaluation with no differences in baseline parameters. The VAS during movement at 24 and 36 hours, quadriceps strength, time up and go test, and knee motion at different time points, and total morphine consumption showed no differences between both groups. There were no procedure-related complications. The surgeon-performed cACB during surgery was feasible and reproducible with similar VAS scores and functional outcomes during hospitalization to anesthesiologist cACB. Level of evidence is Level I, prospective randomized trial.

Comparison of Analgesic Efficacies of the iPACK (Interspace Between the Popliteal Artery and Capsule of the Posterior Knee) and Genicular Nerve Blocks Used in Combination With the Continuous Adductor Canal Block After Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: The interspace between the popliteal artery and capsule of the posterior knee (iPACK) block and the genicular nerve block (GNB) are motor-sparing nerve blocks used for knee pain relief. We compared the analgesic efficacies of ultrasound-guided iPACK block and GNB when combined with continuous adductor canal block after total knee arthroplasty. METHODS: In this randomized control study, 132 total knee arthroplasty patients were assigned to the iPACK, GNB, and iPACK + GNB groups. All patients received combined spinal anesthesia and continuous adductor canal block. The primary outcome was the 8-hour postoperative pain score during movement. Secondary outcomes were pain scores, posterior knee pain, intravenous morphine consumption, and tibial and common peroneal nerve sensorimotor function. All included patients completed the study. RESULTS: The 4-hour and 8-hour postoperative pain scores during movement were significantly lower in the iPACK + GNB group than that in the iPACK group (-2.5 [3.6, 1.3]; P < .001 and -2 [-3, -1]; P < .001, respectively). The differences in rating pain scores and posterior knee pain were not clinically relevant. The iPACK group demonstrated a significantly higher intravenous morphine consumption than did the GNB and iPACK + GNB groups during the first 48 hours postoperatively (P < .001) but were not clinically relevant. There was no incidence of complete sensorimotor blockade in any of the groups. CONCLUSION: The iPACK-GNB combination relieved pain during movement better than the iPACK block alone during the 8 hours postoperatively after total knee arthroplasty in setting of multimodal analgesia such as adductor canal block.

Effect of Adding Perineural Methylprednisolone to Peripheral Nerve Blocks Combined With Intravenous Dexamethasone for Prolonged Postdischarge Analgesia After Fast-track Total Knee Arthroplasty: A Randomized Controlled Trial.

OBJECTIVES: Patients undergoing total knee arthroplasty (TKA) may experience moderate-to-severe subacute pain after hospital discharge that may be undermanaged. We aimed to evaluate the effect of methylprednisolone added to ultrasound-guided peripheral nerve blocks (PNBs) combined with multimodal analgesia including intravenous dexamethasone for prolonged analgesia after early discharge. MATERIALS AND METHODS: We randomized 80 patients who underwent fast-track TKA into 2 groups. All patients received a periarticular injection, PNBs, and multiple doses of intravenous dexamethasone. The methylprednisolone group received 140 mg methylprednisolone in PNBs, while the nonmethylprednisolone group did not. The primary outcome was the incidence of moderate-to-severe pain (Numerical Rating Scale ≥4) during the first 12 postdischarge days. The secondary outcomes included pain scores until 3 postoperative months, incidence of rebound pain, functional performances, patient satisfaction, and adverse events. RESULTS: No significant between-group differences were noted in the incidence of moderate-to-severe pain during the first 12 postdischarge days (nonmethylprednisolone vs. methylprednisolone groups: 70% vs. 69.2%, P=0.941). However, this incidence was significantly higher in the methylprednisolone group between 2 weeks and 1 month (P=0.015) and between 1 and 3 months (P=0.004) postoperatively. No between-group differences in the Numerical Rating Scale scores at the postdischarge time points, incidence of rebound pain, and functional performance results were noted. DISCUSSION: Adding perineural methylprednisolone to ultrasound-guided PNBs for multimodal analgesia with intravenous dexamethasone did not prolong analgesia and improved the functional ability after fast-track TKA within 12 postdischarge days. However, the incidence moderate-to-severe pain may increase between the 2-week and 3-month follow-up.

Two or four injections of platelet-rich plasma for osteoarthritic knee did not change synovial biomarkers but similarly improved clinical outcomes.

We compared two and four intra-articular injections of platelet-rich plasma (PRP) in terms of changes of synovial cytokines and clinical outcomes. One hundred twenty-five patients having knee osteoarthritis (OA) underwent PRP injections at a 6-week interval. Before each PRP injection, synovial fluid aspiration was collected for investigation. Patients were divided into two or four intra-articular PRP injections (group A and B, respectively). Changes in synovial biomarkers were compared with the baseline levels of both groups, and clinical outcomes were evaluated until one year. Ninety-four patients who had completed synovial fluid collection were included for final evaluation, 51 in group A and 43 in group B. There were no differences in mean age, gender, body mass index (BMI), and radiographic OA grading. The average platelet count and white blood cell count in PRP were 430,000/µL and 200/ µL, respectively. There were no changes of synovial inflammatory cytokines (IL-1ß, IL-6, IA-17A, and TNF-alpha), anti-inflammatory cytokines (IL-4, IL-10, IL-13, and IL-1RA), and growth factors (TGF-B1, VEGF, PDGF-AA, and PDGF-BB) between baseline levels and six weeks in group A, and 18 weeks in group B. Both groups had significantly improved clinical outcomes from six weeks including visual analog scale (VAS), patient-reported outcome measures [PROMs; Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index and Short Form-12 (SF-12)], with a significant delayed improvement of performance-based measures [PBMs; time up and go (TUG), 5-time sit to stand test (5 × SST), and 3-min walk test (3-min WT)]. In conclusion, two- or four-PRP intra-articular injection at a 6-week interval for knee OA demonstrated no changes of synovial cytokines and growth factors but similarly improved clinical outcomes from 6 weeks until 1 year.

No Difference in Pain After Spine Surgery with Local Wound Filtration of Morphine and Ketorolac: A Randomized Controlled Trial.

BACKGROUND: Controlling postoperative pain after spinal surgery is important for rehabilitation and patient satisfaction. Wound infiltration with local anesthetics may improve postoperative pain, but true multimodal approaches for achieving analgesia after spinal surgery remain unknown. QUESTIONS/PURPOSES: In this randomized, controlled, double-blind trial after lumbar interbody fusion, we asked: (1) Does multimodal analgesia reduce VAS pain scores by a clinically important amount? (2) Does this analgesic approach reduce the amount of morphine patients consume after surgery? (3) Is this approach associated with fewer opioid-related side effects after surgery? METHODS: This study included 80 adult patients undergoing lumbar interbody fusion who were randomized into two groups: A control group (n = 40) who received infiltration of the surgical incision at the end of the procedure with an injection of 0.5% bupivacaine 100 mg (20 mL) and epinephrine 0.5 mg (0.5 mL), and the multimodal group (n = 40), who received wound infiltration with the same approach but with different medications: 0.5% bupivacaine 92.5 mg (18.5 mL), ketorolac 30 mg (1 mL), morphine 5 mg (0.5 mL), and epinephrine 0.5 mg (0.5 mL). There were no between-group differences in the proportion of patients who were male, nor in the mean age, height, weight, preoperative pain score, or surgical time. All treatments were administered by one surgeon. All patients, the surgeon, and the researchers were blinded to the allocation of patients to each group. Pain at rest was recorded using the VAS. Postoperative morphine consumption (administered using a patient-controlled analgesia pump) and opiod-associated side effects including nausea/vomiting, pruritus, urinary retention, and respiratory depression were assessed; this study was analyzed according to intention-to-treat principles. No loss to follow-up or protocol deviations were noted. We considered a 2-cm change on a 10-cm scale on the VAS as the minimum clinically important difference (MCID). Differences smaller than this were considered unlikely to be important. RESULTS: At no point were there between-group differences in the VAS scores that exceeded the MCID, indicating no clinically important reductions in pain associated with administering multimodal injections. The highest treatment effect was observed at 3 hours that showed only a -1.3 cm mean difference between the multimodal and the control groups (3.2 ± 1.8 versus 4.5 ± 1.9 [95% CI -1.3 to -0.3]; p < 0.001), which was below the MCID. Morphine consumption was very slightly higher in the control group than in the multimodal group (2.8 ± 2.8 versus 0.3 ± 1.0, mean difference 2.47; p < 0.001). The percentage of patients reporting opioid-related side effects was lower in the multimodal group than in the control group. The proportions of nausea and vomiting were higher in the control group (30% [12 of 40] than in the multimodal group (3% [1 of 40]; p = 0.001). All of these side effects were transient and none was severe. CONCLUSIONS: Multimodal wound infiltration with an NSAID and morphine did not yield any clinically important reduction in pain or opioid consumption. Since no substantial benefit of adding these drugs to a patient's aftercare regimen was achieved, and considering the potential risks of administering opioids and NSAIDs (such as, polypharmacy in older patients, serious adverse effects of NSAIDs), we recommend against routine use of this approach in clinical practice. LEVEL OF EVIDENCE: Level I, therapeutic study.

Curved versus straight-cut hinges for open-door laminoplasty: A finite element and biomechanical study.

In this study, the stabilities of the hinge sides of plate-augmented open-door laminoplasties based on cutting in a curved or straight line were compared using a finite element (FE) model and an experimental assessment. Using FE models generated from CT scans of a human subject, straight and curved techniques for cutting the hinge side were evaluated. Compressive forces were applied to both simulated models, and the stress distributions on the respective hinge sites were evaluated by comparing the maximum von Mises stresses. Biomechanical testing procedures were then carried out on porcine cervical vertebrae, with straight- and curved-cut groups loaded to failure, and the corresponding reaction forces on the hinge sites were recorded using a loading cell. The FE analysis results revealed no significant differences between the straight- and curved-cut groups in terms of maximum stress forces on the superior, middle, or inferior portions of the hinge sites. In the experimental study, the curved-cut group withstood higher loads to failure at the hinge site than the straight-cut group. The ability of the curved-cut laminoplasty hinges to withstand higher compressive loading to failure than straight-cut hinges suggests the potential of the proposed technique to reduce the risk of hinge fracture and displacement.

A comparison between repeat discectomy versus fusion for the treatment of recurrent lumbar disc herniation: Systematic review and meta-analysis.

Recurrent lumbar disc herniation is a common negative sequela of primary discectomy. Repeat discectomy versus spinal fusion is constantly debated, and successful outcomes from both treatments remain unclear. Several meta-analysis studies have not reported re-operative rates between the two treatment methods; therefore, we seek to report these outcomes in the following systematic review and meta-analysis design study. The primary objective was to compare re-operative rates between repeat discectomy and fusion treatment. The secondary objectives included comparing clinical improvement, operative time, blood loss, complications, and postoperative hospital stay between repeat discectomy and fusion treatment. The data were gathered from the following sources: PubMed Medline, Ovid Medline, Cochrane database, and Google Scholars. Only comparative studies in humans were selected. There were initially 182 citations found. After the analysis, we found four studies that were compatible with our inclusion criteria. The meta-analysis showed that the re-operative rate seemed to be higher in the discectomy group (9.09%) compared with the fusion group (2.00%), but the difference was not statistically significant. The primary cause of re-operation in the discectomy group is recurrent disc herniation. Two causes of re-operation in the fusion group are adjacent segmental degeneration and implant removal. Operative time and postoperative stay were significantly less in the discectomy group. The improvement rate was not different between the two groups. In conclusion, no difference in re-operation rates between the two surgical treatments was found based on the results of our study. Both treatment techniques have equal improvement rates and complications.

Cervical paraspinal muscle compartment pressure after laminoplasty: A cadaveric study.

Axial neck pain is a common complaint after cervical laminoplasty and the causes are still not well-understood. We hypothesized that abnormal paracervical muscle compartment pressures might be one of them. The cervical paraspinal muscle compartment pressures of 10 cadavers were measured in six different areas under four different conditions. The posterior cervical area was divided into two sides: open side and hinge side. Then each side was divided into upper, middle, and lower areas. The compartment pressures of each area were measured under four different conditions: before and after dissection of posterior paravertebral (paraspinal) muscles, after laminoplasty and after laminoplasty with removal of the spinous processes. There was a statistically significant difference between the pressures after dissection versus after laminoplasty on the hinge side at all upper, middle and lower areas [p < 0.01, <0.001 and =0.009 respectively]. There was a difference in the pressures after laminoplasty between the open and hinge sides [p < 0.001, <0.001 and =0.023 respectively]. We also found the following significant differences: the pressures between before dissection and after laminoplasty on the hinge side, as well as between after laminoplasty and after removal of the spinous process on the hinge side in the upper and middle areas [p < 0.001, =0.0016 and p = 0.002, =0.023 respectively]. Cervical paraspinal muscle compartment pressures on the hinge side were significantly increased after laminoplasty. This may be a contributor to axial neck pain following laminoplasty. The pressure was then significantly decreased after removal of the spinous processes.

Awareness of middle sacral artery pathway: A cadaveric study of the presacral area.

PURPOSE: To assess the anatomic path of the middle sacral artery (MSA) at the presacral area and its relationship to the spinal midline during an axial lumbar interbody fusion (AxiaLif) approach. METHODS: Fifty human cadavers (25 males, 25 females) were used in this study. A transabdominal approach was used to expose the anterior aspect of the L5/S1 intervertebral disc and the presacral space. We measured the size and distance from the spinal midline at the following positions: (a) middle of the L5/S1 disc level, (b) 1 cm below the sacral promontory (SP), and (c) 2 cm below the SP. Each parameter was measured three times by two observers, and the mean value analyzed. RESULTS: The MSA was present and originated from the left common iliac artery in all cadavers with a mean width of 2.14 mm. The position of the MSA in relation to the midline was most commonly on the left side (LS, 56%) followed by the right side (RS, 34%) and midline (ML, 10%). In the LS group, the distance from the midline is relatively constant in the three measured positions with a mean value of (a) 1.78 mm (range, 0-8.17 mm), (b) 2.08 mm (range, 0-7.10 mm), and (c) 2.06 mm (range, 0-9.76 mm). In the RS group, the distance from the midline increased from cephalad to caudad, with a mean value of (a) 1.44 mm (range, 0-9.64 mm), (b) 2.19 mm (range, 0-9.95 mm), and (c) 2.92 mm (range, 0-10.03 mm). CONCLUSIONS: Our study found the presacral anatomic path of the MSA was most commonly at the left of midline. In addition, the right-sided MSA variant had increasing distance from the midline along its anatomic path from cephalad to caudad. Our findings suggest an AxiaLif approach at the left of midline may place the MSA at greatest risk.

Limitations of Using Microsoft Excel Version 2016 (MS Excel 2016) for Statistical Analysis for Medical Research.

Microsoft Excel (MS Excel) is a commonly used program for data collection and statistical analysis in biomedical research. However, this program has many limitations, including fewer functions that can be used for analysis and a limited number of total cells compared with dedicated statistical programs. MS Excel cannot complete analyses with blank cells, and cells must be selected manually for analysis. In addition, it requires multiple steps of data transformation and formulas to plot survival analysis graphs, among others. The Megastat add-on program, which will be supported by MS Excel 2016 soon, would eliminate some limitations of using statistic formulas within MS Excel.