Transversus abdominis plane block for anterior lumbar interbody fusion: a randomized controlled trial.

BACKGROUND CONTEXT: Anterior lumbar interbody fusion (ALIF) is a lumbar arthrodesis technique via an anterior approach that is less invasive than the posterior approaches. However, it is associated with specific pain in the abdominal wall. PURPOSE: The objective of this study was to determine whether performing a bilateral ultrasound-guided Transversus abdominis plane (TAP) block allows a reduction in morphine consumption in the first 24 hours after surgery. STUDY DESIGN: This study is a prospective single-center, randomized, double-blind study. PATIENT SAMPLE: Patients undergoing ALIF surgery were included and randomized into two groups. Both groups received a TAP block performed at the end of surgery with either ropivacaine or placebo. OUTCOME MEASURES: The primary outcome measure was morphine consumption in the first 24 hours. The main secondary outcomes were immediate postoperative pain and opioid-related side effects. METHODS: Intra- and postoperative anesthesia and analgesia protocols where standardized. A bilateral ultrasound-guided TAP block was performed with 75 mg (in 15 mL) of ropivacaine per side or isotonic saline serum depending on their assignment group. RESULTS: Forty-two patients were included in the study (21 per group). Morphine consumption at 24 hours (28 mg [18-35] in the ropivacaine group versus 25 mg [19-37] in the placebo group [p=.503]) were not significantly different between the two groups. CONCLUSION: TAP block with ropivacaine or placebo provided a similar postoperative analgesia when associated with a multimodal analgesia protocol for ALIF.

Morbidity and clinicoradiological outcomes of anterior lumbar arthrodesis using tantalum intervertebral implants.

PURPOSE: The objective of this study was to assess the morbidity of Anterior Lumbar Interbody Fusion (ALIF) using an intervertebral tantalum implant. Tantulum is an extremely porous metallic material which possesses properties of osseointegration, osteoinduction and osteoconduction while offering superior primary stability, compared to other materials more commonly used (polyether ether ketone or PEEK, titanium). Perioperative morbidity, short-term functional outcomes (2 years) and radiographic impaction of implants were also analysed. METHODS: This retrospective monocentric study involved 94 patients operated on between 2014 and 2017 for degenerative disc disease (75%), degenerative spondylolisthesis (3%) or isthmic lytic spondylolisthesis (22%). Sixty-five patients (69%) had isolated ("stand-alone") ALIF procedures, 24 (26%) with associated anterior osteosynthesis and 5 (5%) with associated posterior osteosynthesis. A Kaplan-Meier survival curve was established with surgical revision listed as the main criterion for failure. Perioperative complications were identified. The clinical evaluation at the last follow-up used a Visual Analogue Scale for radicular pain (VAS-R), for lumbar pain (VAS-L) and the Oswestry Disability Index (ODI) score. The impactions, assessed on x-rays, were divided into 2 groups according to severity in order to establish risk factors (RF). RESULTS: The primary objective showed a 2-year survival rate of 94% (95% CI [0.88; 0.99]). Two patients had early surgical revision for impaction and 4 patients had late surgical revision for pseudarthrosis. The rate of perioperative complications was 8.5%, mostly due to vascular causes. At the average follow-up of 33 months (24-59), the clinical results were significantly improved and the impaction rate was 36% in the immediate postoperative period (IPO) and 47% at one year. CONCLUSION: ALIF using an intervertebral tantalum implant is a reliable, reproducible and low morbidity technique. However, it is accompanied by a significant rate of immediate and secondary impaction but without any resounding influence on short-term clinical outcomes. LEVEL OF EVIDENCE: IV.

Retrospective, multicenter, observational study of 112 surgically treated cases of humerus metastasis.

INTRODUCTION: The humerus is the second most common site for metastasis in the peripheral skeleton. These humeral metastases (HM) occur in the midshaft in 42% to 61% of cases and theproximal humerus in 32% to 45% of cases. They are often secondary to primary breast (17-31%), kidney (13-15%) or lung (11-24%) cancer. The optimal surgical treatment between intramedullary (IM) procedures, fixation or arthroplasty is still being debated. HYPOTHESIS: We hypothesized that fixation and/or arthroplasty are safe and effective options for controlling pain and improving the patients' function. MATERIALS AND METHODS: Between 2004 and 2016, 11 French hospitals included 112 continuous cases of HM in 54 men (49%) and 57 women (51%). The average age was 63.7±13.4 years (30-94). The HM occurred in the context of primary breast (30%), lung (23%) or kidney (21%) cancers. The HM was proximal in 35% of cases, midshaft in 59% and distal in 7% of cases. Surgery was required in 69% of patients because of a pathological fracture. The surgical procedure consisted of bundle pinning, plate fixation, arthroplasty or locked IM nailing in 6%, 11%, 14% and 69% of patients, respectively. RESULTS: Seven patients (6%) had to be reoperated due to surgical site complications including two infections and four fractures (periprosthetic or away from implant). Twelve patients (11%) experienced a general complication. The overall survival was 16.7 months, which was negatively and significantly impacted by the occurrence of a fracture, a diaphyseal location and the type of primary cancer. At the final assessment, 75% had normal or subnormal function and more than 90% were pain-free or had less pain. The final function was not related to the occurrence of a fracture or etiology of the metastasis. In epiphyseal and metaphyseal HM, there was a trend to better function after shoulder arthroplasty than after plate fixation or IM nailing. CONCLUSIONS: Our initial hypothesis was confirmed. Our findings were consistent with those of other published studies. Based on our findings, we recommend using static locked IM nailing with cementoplasty for mid-shaft lesions and modular arthroplasty for destructive epiphyseal or metaphyso-epiphyseal lesions. The criteria for assessing humeral fracture risk should be updated to allow the introduction of a preventative procedure, which contributes to better survival. LEVEL OF EVIDENCE: IV, retrospective study.

Does performing outpatient total hip arthroplasty contribute to early complications and readmissions? Retrospective case-control study of 50 patients.

INTRODUCTION: Advances in anesthesia and surgical practices have allowed total hip arthroplasty to be performed as an outpatient procedure. The aim of this study was to demonstrate its feasibility in a selected population compared to a group of inpatients by analyzing the cumulative length of hospital stay, complications and readmissions. PATIENTS AND METHODS: This was a retrospective, single-surgeon study of continuous adult patients between October 2016 and May 2018 who underwent primary total hip arthroplasty (THA) and were eligible to undergo this procedure either as an inpatient or outpatient based on their health and comprehension level. Two groups of patients were set up. The outpatient group was given a preoperative treatment education session. The same anesthesia protocol and surgical technique was used in both groups. RESULTS: Fifty outpatients were compared to 77 inpatients. In the outpatient group, the patients were significantly younger, had a greater walking distance and were predominantly male. The two groups were comparable in terms of functional and medical criteria. The mean cumulative hospital stay was 1.2days in the outpatient group with one discharge failure because of nausea and vomiting, versus 5.1days in the inpatient group (p<0.0001). There were three complications in each group (p=1.00). There were three readmissions in the outpatient group and four in the inpatient group (p=1.00) that were of similar length (p=0.86). There was no difference in the mean number of additional office visits over this period between the two groups. CONCLUSION: Outpatient THA procedures can be done reliably and safely in France in a carefully selected population without increasing the complication rate or readmission rate. Expanding this practice requires implementing specific anesthesia and surgery protocols, along with close perioperative monitoring to help manage risk. LEVEL OF EVIDENCE: IV (retrospective cohort study).