Comparison of Outcomes between Robot‐Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion and Oblique Lumbar Interbody Fusion in Single‐Level Lumbar Spondylolisthesis

ObjectiveTo compare the safety and effectiveness of robot‐assisted minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) and oblique lumbar interbody fusion (OLIF) for the treatment of single‐level lumbar degenerative spondylolisthesis (LDS).MethodsThis is a retrospective study. Between April 2018 and April 2020, a total of 61 patients with single‐level lumbar degenerative spondylolisthesis and treated with robot‐assisted OLIF (28 cases, 16 females, 12 males, mean age 50.4 years) or robot‐assisted Mis‐TLIF (33 cases, 18 females, 15 males, mean age 53.6 years) were enrolled and evaluated. All the pedicle screws were implanted percutaneously assisted by the TiRobot system. Surgical data included the operation time, blood loss, and length of postoperative hospital stay. The clinical and functional outcomes included Oswestry Disability Index (ODI), Visual Analog scores (VAS) for back and leg pain, complication, and patient''s satisfaction. Radiographic outcomes include pedicle screw accuracy, fusion status, and disc height. These data were collected before surgery, at 1 week, 3 months, 6 months, and 12 months postoperatively.ResultsThere were no significantly different results in preoperative measurement between the two groups. There was significantly less blood loss (142.4 ± 89.4 vs 291.5 ± 72.3 mL, P < 0.01), shorter hospital stays (3.2 ± 1.8 vs 4.2 ± 2.5 days, P < 0.01), and longer operative time (164.9 ± 56.0 vs 121.5 ± 48.2 min, P < 0.01) in OLIF group compared with Mis‐TLIF group. The postoperative VAS scores and ODI scores in both groups were significantly improved compared with preoperative data (P < 0.05). VAS scores for back pain were significantly lower in OLIF group than Mis‐TLIF group at 1 week (2.8 ± 1.2 vs 3.5 ± 1.6, P < 0.05) and 3 months postoperatively (1.6 ± 1.0 vs 2.1 ± 1.1, P < 0.05), but there was no significant difference at further follow‐ups. ODI score was also significantly lower in OLIF group than Mis‐TLIF group at 3 months postoperatively (22.3 ± 10.0 vs 26.1 ± 12.8, P < 0.05). There was no significant difference in the proportion of clinically acceptable screws between the two groups (97.3% vs 96.2%, P = 0.90). At 1 year, the OLIF group had a higher interbody fusion rate compared with Mis‐TLIF group (96.0% vs 87%, P < 0.01). Disc height was significantly higher in the OLIF group than Mis‐TLIF group (12.4 ± 3.2 vs 11.2 ± 1.3 mm, P < 0.01). Satisfaction rates at 1 year exceeded 90% in both groups and there was no significant difference (92.6% for OLIF vs 91.2% for Mis‐TLIF, P = 0.263).ConclusionRobot‐assisted OLIF and Mis‐TLIF both have similar good clinical outcomes, but OLIF has the additional benefits of less blood loss, less postoperative hospital stays, higher disc height, and higher fusion rates. Robots are an effective tool for minimally invasive spine surgery.     

Anterior cervical discectomy and fusion for noncontiguous cervical spondylotic myelopathy

Background:Noncontiguous cervical spondylotic myelopathy (CSM) is a special degenerative disease because of the intermediate normal level or levels between supra and infraabnormal levels. Some controversy exists over the optimal procedure for two noncontiguous levels of CSM. The study was to evaluate the outcomes of the anterior cervical discectomy and fusion (ACDF) with zero-profile devices for two noncontiguous levels of CSM.Results:The mean followup was 48.59 months (range 24-56 months). The average operative time and blood loss was 105.29 min and 136.47 ml, respectively. The preoperative JOA score was 8.35, which significantly increased to 13.7 at the final followup (P < 0.01). The NDI score was significantly decreased from preoperative 13.06 to postoperative 3.35 (P < 0.01). The operation also provided a significant increase in the cervical lordosis (P < 0.01) from preoperative 10.17° to postoperative 17.06°. The fusion rate was 94.1% at 6 months postoperatively, and 100% at 12 months after surgery. The mean SWAL-QOL score decreased from preoperative 68.06 to immediate postoperatively 65.65 and then increased to 67.65 at final followup. There was a statistically significant difference between preoperative and immediate postoperatively values (P < 0.05), but none between preoperative and at final followup (P > 0.05). Cerebrospinal fluid leak, dysphagia and radiological adjacent segment degeneration occurred in one patient, respectively.Conclusion:The ACDF with zero-profile devices is generally effective and safe in treating two noncontiguous levels of CSM.     

Psychological and Functional Comparison between Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Single‐Level Lumbar Spinal Stenosis

ObjectiveThe aim of this study was to investigate whether treatment with minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) causes patients suffering from lumbar spinal stenosis (LSS) to experience less anxiety and better clinical efficacy than open transforaminal lumbar interbody fusion (TLIF).MethodsIn this retrospective cohort study, we analyzed 86 patients, including 46 male patients and 41 female patients, who suffered from single‐segmental lumbar spinal stenosis in our department between January 2016 and January 2018. They were divided into two groups: a control group (n = 46), for patients who underwent open TLIF surgery, and an experimental group (n = 40), for patients who underwent Mis‐TLIF surgery. All patients were evaluated based on operation time, intraoperative blood loss, hospital stay, visual analogue scale (VAS), Oswestry disability index (ODI), hospital anxiety depression scale (HADS), fusion rate, and complications (screw misplacement and loosening, cerebrospinal fluid leakage, infection, and delayed wound healing). Patient characteristics were compared within and between groups.ResultsThe average incision length was 3.64 ± 0.476 cm in the experimental group, which was smaller than that (8.11 ± 2.406 cm) in the control group (P < 0.05). The operation time of the experimental group was a little longer than that of the control group. The intraoperative blood loss and hospital stay in the experimental group were less than those in the control group.The mean preoperative low back pain VAS score was 7.525 ± 1.432 in the experimental group and 7.087 ± 1.799 in the control group (P > 0.05). The low back pain VAS scores on postoperative day 3 and at 3, 6, and 12 months postoperatively were 5.000 ± 0.987, 4.075 ± 0.997, 2.150 ± 0.834, and 1.450 ± 0.639 in the experimental group, respectively; these scores were lower than those in the control group (6.870 ± 1.572, P < 0.05; 4.630 ± 1.103, P < 0.05; 2.630 ± 1.103, P < 0.05; and 2.326 ± 1.034, P < 0.05, respectively). There was no obvious difference in the leg pain VAS scores between the two groups at all follow‐up points.The mean preoperative ODI score was 58.700% ± 19.703% in the experimental group and 61.696% ± 17.583% in the control group (P > 0.05). The ODI scores at postoperative months 3, 6, and 12 were 25.225% ± 5.554%, 20.150% ± 7.698%, and 16.125% ± 9.565% in the experimental group; these scores were lower than those in the control group (49.130% ± 14.805%, P < 0.05; 34.044% ± 15.148%, P < 0.05; and 29.282% ± 132.567%, P < 0.05, respectively).The mean preoperative HADS score was 14.475 ± 3.113 in the experimental group and 13.391 ± 2.824 in the control group (P > 0.05). However, the mean HADS scores on postoperative day 3 in the experimental group was 8.500 ± 2.000, decreasing obviously compared to the preoperative scores (P < 0.05). The mean postoperative HADS score on postoperative day 3 in the control group was 12.734 ± 1.949, which had not decreased significantly compared to the preoperative score (P > 0.05). The HADS scores in the experimental group was lower than that in the control group on postoperative day 3 (P < 0.05).In the correlation analysis, the incision length was correlated to the HADS scores on postoperative day 3 (r = 0.527, P < 0.05). The HADS scores on postoperative day 3 were positively correlated with the low back pain VAS scores on the same day (r = 0.388, P < 0.05). The HADS scores on postoperative day 3were positively correlated with the ODI scores at 3‐month (r = 0.460, P < 0.05), 6‐month (r = 0.429, P < 0.05), and 12‐month follow up (r = 0.349, P < 0.05).Fusion rates were not significantly different between the two groups. There was no screw misplacement and loosening, infection, or delayed wound healing in either group. The cerebrospinal fluid leakage rate in the control group was higher than that in the experimental group.ConclusionPatients undergoing Mis‐TLIF experience less anxiety and have better outcomes than those who undergo open TLIF. The lower level of anxiety experienced by patients undergoing Mis‐TLIF is positively correlated with postoperative VAS and ODI scores.     

The impact of pain on daily activities following open mesh inguinal hernia repair

Background In groin hernia repair studies, chronic pain is a frequently used primary endpoint. However, its impact on daily life activities has been less investigated. Such an outcome is relevant for the patient and surgeon and cannot be extrapolated out of pain scores. The Pain Disability Index (PDI), a questionnaire wherein patients rate their impairment, could reveal the consequences of pain. The PDI was therefore introduced in a trial upon open mesh-based inguinal hernia repair. Methods A total of 172 patients received an open preperitoneal repair or Lichtenstein procedure. Primary endpoints for this report were the PDI scores measured preoperatively, after 2 weeks and 3 months. The Visual Analogue Scale pain (VAS) scores were assessed simultaneously. Chronic pain was defined as any VAS score at 3 months postoperatively. Results The PDI scores of all measure moments were available for 146 patients (85%). A correlation between the PDI and VAS score was found at all moments (P < 0.001). A total of 47 patients reported chronic pain. The intensity of their pain correlated more significantly with the PDI than VAS scores at 2 weeks postoperatively (R = 0.286, P<0.001 vs. R = 0.175, P = 0.036). Thirty chronic pain patients reported restrictions. The main disabilities were for the recreation, occupation and sexual subscale. Their PDI scores were not influenced whether work was rated as light or heavy (P = 0.570). Twelve patients without chronic pain reported impairment in daily life (mean PDI score 8.8 ± 10.8). Conclusion The PDI is feasible in inguinal hernia repair and can be used as an adjuvant in pain measurement. It can identify patients still suffering postoperatively who might otherwise be missed. Furthermore, the PDI could serve as a predictor for chronic pain.     

Comprehensive Pain Control Strategy in Minimally Invasive Mitral Valve Repair

Purpose: The effect of our comprehensive strategy to reduce pain after minimally invasive mitral valve repair through a right mini-thoracotomy was assessed retrospectively.Methods: Our comprehensive strategy constituted the following: planned rib cutting to avoid rib injury, sufficient intercostal muscle division to mobilize the cut rib, limiting the number of intercostal ports, avoiding nerve entrapment, continuous extra-pleural intercostal nerve block, and regular use of oral non-steroidal anti-inflammatory drugs. We compared patients treated with this comprehensive strategy (Group S, n = 13) and patients before this strategy was implemented (Group C, n = 13). We used a numerical rating scale (NRS) as a pain scale during the first 3 days postoperatively.Results: The average NRS was significantly lower in Group S (0.82 ± 0.49) than in Group C (2.40 ± 1.46) (P <0.01). The maximum NRS was also significantly lower in Group S (3.23 ± 1.17) than in Group C (5.69 ± 2.43) (P <0.01). The number of patients using additional single-dose analgesic were significantly less in Group S (23.1%) than in Group C (84.6%) (P <0.01).Conclusion: Our comprehensive pain control strategy effectively reduced postoperative pain in minimally invasive mitral valve repair.     

Effect of Duration of Symptoms on the Clinical and Functional Outcomes of Lumbar Microdiscectomy: A Randomized Controlled Trial

ObjectivesThe objective is to determine whether the preoperative duration of symptoms can affect the clinical and functional outcomes after microdiscectomy.MethodThis study is a single blind randomized controlled trial with level 1 evidence. From 3 January 2016 to 15 February 2017, 122 adult patients with symptomatic lumbar disc herniation were divided randomly by computer system into three groups were treated by microdiscectomy at 6 weeks, 3 months and 6 months from onset of symptoms respectively. Ninety‐seven patients, age (19–47) years, 42 males and 55 females, were analyzed at the end of this study with 3 years of follow up. Primary outcome measures are Oswestry Disability Index (ODI), Roland‐Morris Questionnaire (RMQ) and Visual Analogue Scale (VAS) for back pain and leg pain. Secondary outcome measures are post‐operative complications, length of hospital stay and time of return to daily activities.ResultsThere was significant difference in VAS for back pain among study groups (P = 0.002) at 2 weeks). There were significant differences in VAS for leg pain among study groups (P < 0.001) at 2 weeks and at 3 months (P = 0.003). There was significant difference in ODI among study groups at 2 weeks, 3, 6 months, 1, 2 and 3 years (P = 0.037 at 2 weeks and P < 0.001 at other periods of assessments) and we found that the mean of ODI in group 6 weeks was better than group 3 months and this was better than group 6 months in all periods of assessment. Group 6 weeks was better than group 3 months and this was better than group 6 months in postoperative improvements regarding RMQ with significant difference at 2 weeks postoperatively (P < 0.001) and at 3 months postoperatively (P < 0.001).ConclusionDuration of preoperative symptoms, in patients with lumbar disc herniation, can affect the clinical and functional outcomes after lumbar microdiscectomy as the shorter duration of symptoms resulted in better postoperative clinical and functional outcomes.     

单节段前路椎体次全切钛网植骨融合术后颈椎三维活动度的临床观察

目的:研究脊髓型颈椎病患者接受单节段前路椎体次全切钛网植骨融合术(anterior cervical corpectomy and fusion,ACCF)术后颈椎三维活动度的变化规律。方法 :对2015年2月至2016年4月期间收治的23例脊髓型颈椎病患者进行回顾性研究,其中男11例,女12例,平均年龄(54.6±13.3)岁。患者术前经问诊、查体及影像学检查明确诊断为脊髓型颈椎病,均行单节段ACCF手术进行治疗。通过三维颈椎活动度测量仪对患者手术前后颈椎三维活动度进行比较,并采用JOA评分和VAS评分评价手术效果。结果:入组患者平均随访时间为(9.4±1.6)个月。术后3个月颈椎活动度与术前比较,除左旋转外,其他方向均明显低于术前(P0.05)。术后6个月颈椎活动度与术前比较,6个方向上的活动度与术前差异均无统计学意义(P0.05)。术后9个月颈椎活动度与术前比较,右侧屈、左旋转方向上的活动度明显高于术前(P0.05)。术后6个月颈椎活动度与术后3个月比较,后伸方向活动度明显高于术后3个月(P0.05)。术后9个月颈椎活动度与术后6个月比较,后伸、右侧屈、左侧屈及左旋转方向上的活动度明显高于术后6个月(P0.05)。术后各时间点JOA评分均明显高于术前(P0.05)。术后各时间点VAS评分均明显低于术前(P0.05)。结论:单节段ACCF术后颈椎三维活动度的变化表明,术后短期内活动度下降,之后活动度增加并优于术前水平,同时神经功能得到显著改善。但术后近期和远期活动度变化以及多节段ACCF术后活动度变化有待进一步研究。     

Effects of methylprednisolone on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery: A randomized controlled trial

Study objectiveEvidence from previous studies indicates that glucocorticoids offer effective postoperative analgesia and improve the quality of recovery (QoR). The aim of this study was to evaluate the efficacy of preoperative methylprednisolone on early postoperative pain and QoR following thoracoscopic lung surgery.DesignA prospective, single-center, three-arm, double-blinded, randomized trial.SettingTertiary university hospital.PatientsAdult patients aged ≥18 years undergoing thoracoscopic lung surgery were eligible for participation.InterventionsPatients enrolled in this study were randomized to receive preoperative methylprednisolone (40 mg or 120 mg) or identical volumes of 0.9% saline.MeasurementsThe primary outcome was the proportion of moderate-to-severe pain (numerical rating scale [NRS] ≥ 4 when coughing during pulmonary rehabilitation exercises) on the first day postoperatively. The postoperative pain scores, QoR-15 scores and other secondary outcomes were also recorded.Main resultsOf the 180 enrolled patients, 173 patients were included in the primary analysis. The results showed that the proportion of moderate-to-severe pain was not significantly different between the combined methylprednisolone group and the placebo group (51.7% vs. 64.9%; absolute difference, 13.2%; 95% CI, −2.1% to 29.3%; P = 0.10). Patients who received methylprednisolone treatment had lower pain scores at rest and coughing on the first day after surgery than those who received placebo treatment, with mean differences of 0.5 and 0.7, respectively (P < 0.01). QoR-15 scores were higher in patients treated with methylprednisolone at day 1 (mean difference, 6.9; P < 0.001) and day 2 (mean difference, 7.2; P < 0.001) than in patients who received placebo treatment. No side-effects associated with methylprednisolone treatment were observed.ConclusionsOur findings suggested that preoperative methylprednisolone (either high or low dose) has limited impact on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery, with no clinically relevant benefits detected when compared with placebo.Trial registrationChinese Clinical Trail Register (identifier: ChiCTR1900021020).     

Sexual health of women with pelvic floor disorders

Preemptive analgesia in vaginal surgery has had conflicting efficacy reported in the existing literature. This study was designed to clarify the usefulness of preemptive local analgesia (PLA) in patients undergoing vaginal hysterectomy. A prospective, randomized, double-blinded trial of PLA in 90 women undergoing vaginal hysterectomy was conducted. PLA consisted of 20 ml of 0.5% bupivacaine with 1:200,000 epinephrine injected in a paracervical-type fashion. Total narcotic use and pain (using a visual analog scale (VAS)) was recorded at 30 min, 3, 12, and 24 h postoperatively. The mean total dose of narcotic was significantly less in the PLA group versus the placebo group (P = 0.009) at every time point postoperatively. Additionally, the mean pain VAS 30 min and 3 h postoperatively was 43% (P = 0.003) and 33% (P = 0.02) lower, respectively, in the PLA group. PLA with bupivacaine prior to vaginal hysterectomy is associated with significantly lower pain scores and a reduction in narcotic use postoperatively.     

Relationship between Preoperative Neuroradiological Findings and Intraoperative Bulbocavernosus Reflex Amplitude in Patients with Intradural Extramedullary Tumors

The current study aimed to evaluate the relationship between preoperative neuroradiological findings and intraoperative bulbocavernosus reflex (BCR) amplitude in patients with intradural extramedullary tumors. A total of 24 patients with lesions below the 12th thoracic vertebra were included in the analysis. Objective and subjective urinary symptoms were investigated using data obtained from medical records and the core lower urethral symptom score (CLSS) questionnaire. The lesion compression rate was evaluated with MRI. In the epiconus-to-conus medullaris (Epi-CM) group, BCR amplitude changes were found to be correlated with the compression rate (p <0.05). The preoperative CLSS of the group with a BCR amplitude of <50% was worse than that of the group with ≥50% (p <0.01). The group did not experience symptom improvement 6 months postoperatively based on the CLSS. The preoperative CLSS of the group with compression rate of ≥80% on imaging was worse than that of the group with <80% (p <0.05). In the group with preoperative compression rate of ≥80%, CLSS at 1 month and 6 months postoperatively was improved as compared to preoperative CLSS (p <0.01, p <0.05). Hence, BCR amplitude changes are associated with the degree of lesion compression on preoperative images and pre- and postoperative urinary symptoms. Patients with intradural extramedullary Epi-CM lesions with strong compression are likely to present with low BCR amplitude and worsened postoperative symptoms. It is considered that the risk of postoperative urinary symptoms increases even with careful surgical manipulation under these conditions.     

Athletes and Nonathletes Show No Difference in Symptoms or Function Prior to Knee Surgery,but Those With Chronic Symptoms Show Increased Pain Catastrophizing and Kinesiophobia

PurposeTo determine whether preoperative psychological status before outpatient knee surgery is influenced by athletic status, symptom chronicity, or prior surgical history.MethodsInternational Knee Documentation Committee subjective scores (IKDC-S), Tegner Activity Scale scores, and Marx Activity Rating Scale scores were collected. Psychological and pain surveys included the McGill pain scale, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia 11, Patient Health Questionnaire 9, Perceived Stress Scale, New General Self-Efficacy Scale, and Life Orientation Test–Revised for optimism. Linear regression was used to determine the effects of athlete status, symptom chronicity (>6 months or ≤6 months), and history of prior surgery on preoperative knee function, pain, and psychological status after matching for age, sex, and surgical procedure.ResultsIn total, 497 knee surgery patients (247 athletes, 250 nonathletes) completed a preoperative electronic survey. All patients were age 14 years and older and had knee pathology requiring surgical treatment. Athletes were younger than nonathletes on average (mean [SD], 27.7 [11.4] vs 41.6 [13.5] years; P < .001). The most frequently reported level of play among athletes was intramural or recreational (n = 110, 44.5%). Athletes had higher preoperative IKDC-S scores (mean [SE], 2.5 [1.0] points higher; P = .015) and lower McGill pain scores compared to nonathletes (mean [SE] 2.0 [0.85] points lower; P = .017). After matching for age, sex, athlete status, prior surgery, and procedure type, having chronic symptoms resulted in higher preoperative IKDC-S (P < .001), pain catastrophizing (P < .001), and kinesiophobia scores (P = .044).ConclusionsAthletes demonstrate no difference in symptom/pain and function scores preoperatively when compared to nonathletes of similar age, sex, and knee pathology, as well as no difference in multiple psychological distress outcomes measures. Patients with chronic symptoms have more pain catastrophizing and kinesiophobia, while those who have had prior knee surgeries have slightly higher preoperative McGill pain score.Level of EvidenceLevel III, cross-sectional analysis of prospective cohort study data.     

Blood loss during radical retropubic prostatectomy: relationship to morphologic features on preoperative endorectal magnetic resonance imaging

Objectives. To determine whether morphologic features at preoperative magnetic resonance imaging (MRI) are related to intraoperative blood loss during radical retropubic prostatectomy.Methods. Endorectal MRI was performed in 143 patients with newly diagnosed prostate cancer before radical retropubic prostatectomy. Two independent readers rated the prominence of the periprostatic veins (on the basis of number and size) at four anatomic sites on a 3-point scale. Other features analyzed were prostate volume and interspinous diameter.Results. A prominence of the anterior and posterior apical periprostatic veins was positively associated with blood loss (correlation coefficient = 0.22 and 0.17 and P <0.01 and <0.05, respectively). Blood loss was not related to prostate volume (correlation coefficient = 0.02, P = 0.8) or interspinous diameter (correlation coefficient = 0.01, P = 0.9). The site-specific scores of both readers demonstrated positive agreement, with Pearson’s correlation coefficients of 0.51 to 0.65 (P <0.01).Conclusions. A marked prominence of the apical periprostatic veins on preoperative MRI is associated with greater intraoperative blood loss during radical retropubic prostatectomy. Other morphologic factors appear unrelated to the amount of intraoperative blood loss.     

Early Postoperative Pain After Keyless Abdominal Rope-Lifting Surgery

Methods:During a 20-month period, 77 women underwent surgery for a benign ovarian cyst. Keyless abdominal rope-lifting surgery and conventional carbon dioxide laparoscopy techniques were used for the operations in 32 women and 45 women, respectively. The 2 operative techniques were compared with regard to demographic characteristics; preoperative, intraoperative, and postoperative data including early postoperative pain scores; and frequency of shoulder pain and analgesic requirements.Results:Data regarding demographic characteristics, preoperative findings, cyst diameters and rupture rates, intra-abdominal adhesions, intraoperative blood loss, and postoperative hospital stay did not differ between groups (P > .05). However, the mean operative and abdominal access times were significantly longer in the keyless abdominal rope-lifting surgery group (P < .05). Visual analog scale pain scores at initially and at the second, fourth, and 24th hours of the postoperative period were significantly lower in the keyless abdominal rope-lifting surgery group (P < .05). Similarly, keyless abdominal rope-lifting surgery caused significantly less shoulder pain and additional analgesic use (P < .05).Conclusion:Keyless abdominal rope-lifting surgery seems to cause less pain in the management of benign ovarian cysts in comparison with conventional carbon dioxide laparoscopy.     

Outcomes of total knee arthroplasty following high tibial osteotomy

Background:

Total knee arthroplasty (TKA) following high tibial osteotomy (HTO) is a technically demanding procedure with varying results. The purpose of our study was to analyze the clinicoradiological results of TKA following HTO and to identify the factors that may influence the final outcome.

Materials and Methods:

55 patients (58 knees) who had undergone a previous HTO were treated with a TKA from 1991 to 2009. There were 34 female and 21 male patients. The average age was 61.9 years (range 52-82 years) and the average weight was 79.5 kg (range 54-106 kg), with an average body mass index of 29.6 (range 21.8-34.6) at the time of TKA. The knee society scores (KSSs) and knee society functional scores were evaluated for every patient pre and postoperatively and the results evaluated.

Results:

The mean period of followup was 11.2 years (range 3-18 years) and the patients were followed up every year. The average KSS score at final followup improved from 38.5 (range 0-80 points) preoperatively to 88.5 postoperatively (range 35-95 points) (P < 0.05). The mean femorotibial angle corrected from 6.8 degrees (range 5-12°) varus preoperatively to a valgus of 4.4 (2-8°) degrees postoperatively. The average joint line height improved to an average of 9.6 mm (range 4.4-22 mm) (P < 0.01) at the last followup. The average Insall Salvatti Ratio also improved (average 1.11 preoperative - 1.21 average postoperative) (P < 0.05). The average range of motion improved to 108° (range 85°-125°) from 76° preoperative (range 55°-100°) (P < 0.01).

Conclusion:

Although TKA postHTO is a demanding surgery however, with newer component designs, results are comparable to primary TKA. Technical difficulties in exposure can sometimes lead to component malpositioning, which can affect the final outcome. Inadequate soft tissue balancing and limb malalignment should always be kept in mind. Regular followup to look for evidences of loosening is advised in such patients].     

Do Relaxation Exercises Decrease Pain After Arthroscopic Rotator Cuff Repair? A Randomized Controlled Trial

BackgroundPain after rotator cuff repair is commonly managed with opioid medications; however, these medications are associated with serious adverse effects. Relaxation exercises represent a potential nonpharmacologic method of pain management that can be easily implemented without substantial adverse effects; however, the effects of relaxation exercises have not been studied in a practical, reproducible protocol after arthroscopic rotator cuff repair.Questions/purposes(1) Does performing relaxation exercises after arthroscopic rotator cuff repair (ARCR) decrease pain compared with standard pain management medication? (2) Does performing relaxation exercises after ARCR decrease opioid consumption? (3) What proportion of patients who used the relaxation techniques believed they decreased their pain level, and what proportion continued using these techniques at 2 weeks? (4) Does performing relaxation exercises after ARCR affect shoulder function?MethodsDuring the study period, 563 patients were eligible for inclusion; however, only 146 were enrolled, randomized, and postoperatively followed (relaxation group: 74, control group: 72); 68% (384 of 563) of patients were not contacted due to patient and research staff availability. Thirty-three patients were unenrolled preoperatively or immediately postoperatively due to change in operative procedure (such as, only debridement) or patient request; no postoperative data were collected from these patients. Follow-up proportions were similar between the relaxation and control groups (relaxation: 80%, control: 81%; p = 0.90). The relaxation group received and reviewed educational materials consisting of a 5-minute video and an educational pamphlet explaining relaxation breathing techniques, while the control group did not receive relaxation education materials. Patients recorded their pain levels and opioid consumption during the 5 days after ARCR. Patients also completed the American Shoulder and Elbow Surgeons shoulder score preoperatively and 2, 6, 13, 18, and 26 weeks postoperatively. Linear mixed models were created to analyze postoperative pain, opioid consumption measured in morphine milligram equivalents (MMEs), and shoulder function outcomes. A per-protocol approach was used to correct for patients who were enrolled but subsequently underwent other procedures.ResultsThere was no difference in pain scores between the relaxation and control groups during the first 5 days postoperatively. There was no difference in pain scores at 2 weeks postoperatively between the relaxation and control groups (3.3 ± 3 versus 3.5 ± 2, mean difference -0.22 [95% CI -1.06 to 0.62]; p = 0.60). There was no difference in opioid consumption during the first 5 days postoperatively between the relaxation and control groups. The use of relaxation exercises resulted in lower 2-week narcotics consumption in the relaxation group than in the control group (309 ± 241 MMEs versus 442 ± 307 MMEs, mean difference -133 [95% CI -225 to -42]; p < 0.01). Sixty-two percent (41 of 66) of patients in the relaxation group believed the relaxation exercises decreased their pain levels. Fifty-two percent (34 of 66) were still performing the exercises at 2 weeks postoperatively. During the 6-month follow-up period, there was no difference in shoulder function between the relaxation and control groupsConclusionThe preoperative administration of quick, basic relaxation exercises allowed patients to use appreciably lower opioid analgesic doses over the first 2 weeks after ARCR, without any worsening of pain scores. We consider this result promising but preliminary; it is possible that a more intense mindfulness intervention—the one we studied here was disseminated using only a 5-minute video—would deliver reductions in pain and further reductions in opioid usage.Level of EvidenceLevel II, therapeutic study.     

Clinical application of helium neon (632 nm) plus infrared diode laser GaAIAs (830 nm) and CO2laser in treatment of onychomycotic nails

Onychomycosis (fungal infection of the toe nail) is difficult to cure. The aim of this study was to evaluate the method of surgical avulsion using a CO₂laser (7W, 0.1 mm) and using a new protocol of low level laser therapy Helium Neon (632 nm, 1.5 mW, 2 J cm^–2) plus infrared diode laser GaAIAs (830 nm, 50 mW, 4 J cm^–2) every other day to improve the recurrence rate, pain score and healing time. Seventy-eight patients were divided into three groups (A, B and C). The ANOVA statistical tests showed that there was a significant difference between the group A, B and B, C (P<0.005) in the measured mean healing time and pain score but no statistical difference between the group A and C (P<0.01). It was concluded that low level laser therapy reduced pain, improved the healing time and had a lower recurrence rate.     

Functional outcomes after arthroscopic treatment of lateral epicondylitis

Background  The purpose of this study was to evaluate surgical outcomes of arthroscopic débridement for lateral epicondylitis using a validated, patient-assessed scoring system as well as conventional outcome measures. We also wanted to identify potential predictive factors that may be associated with the outcomes. Methods  A total of 20 elbows in 18 patients with chronic lateral epicondylitis who underwent arthroscopic surgery were included. There were nine men and nine women with a mean age of 54 years (range 42–71 years). Operative treatment consisted of débridement of the extensor carpi radialis brevis (ECRB) origin and resection of the radiocapitellar synovial plica interposed in the joint. Outcomes were assessed using a patient rating, visual analogue scale (VAS) pain score, the Japanese Orthopaedic Association (JOA) elbow score, and the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire. The average length of follow-up was 28 months (range 24–40 months). Results  After surgery, according to the patients’ reports, 14 of 20 elbows were much better, and 6 elbows were better. A mean preoperative VAS pain score at rest of 3.9 points improved to 0.3 points (P < 0.0001), and that during activity improved from 7.8 points to 0.9 points (P < 0.0001). The mean preoperative JOA elbow score of 29 points was improved to 90 points (P < 0.0001). The mean postoperative DASH score was 10.6 (range 0–50). Absent of T2-weighted high signal focus of the ECRB origin on preoperative magnetic resonance imaging (MRI) (P = 0.02) and receiving public assistance (P = 0.01) were significantly associated with worse DASH scores. Conclusions  Arthroscopic release was a satisfactory procedure for chronic lateral epicondylitis. Preoperative MRI of the ECRB origin and socioeconomic factors were significantly associated with postoperative residual symptoms evaluated with the DASH score.     

Anteroinferior Psoas Technique for Oblique Lateral Lumbar Interbody Fusion: Technical Note and Case Series

ObjectiveThe aim of the present paper was to evaluate cases of lumbar degenerative diseases treated with oblique lateral interbody fusion (OLIF) using a modified lateral approach (i.e. anteroinferior psoas exposure under direct vision) and to analyze the effect and safety of this approach.MethodsFrom June 2016 to April 2019, a total of 226 patients with an average age of 65.5 ± 16.2 years (98 men and 128 women) with degenerative lumbar diseases who underwent the AIP approach of OLIF were followed up and analyzed retrospectively. Data concerning operative and clinical parameters were collected, including operative time, intraoperative estimated blood loss, duration of postoperative hospital stay, and time to ambulation after surgery. For the assessment of clinical outcomes, the visual analogue scale (VAS) score (for back pain) and the Oswestry disability index (ODI) were calculated. Complications were also recorded as surgical exposure approach‐related complications. More than 6 months after surgery, 132 patients consented to having MRI examinations to evaluate the psoas muscle atrophy when they were followed up.ResultsThe mean operative time was 82.5 ± 31.6 min. The mean operative time for each segment of OLIF was 43.3 ± 15.5 min. The mean blood loss was 48.0 ± 11.6 mL. The mean blood loss for each segment of OLIF was 25.3 ± 10.1 mL. No patients needed blood transfusion intraoperatively or postoperatively. The mean hospital stay was 4.1 ± 2.1 days. All patients were followed up for 12–31 months (mean 18.2 months). Clinical assessment showed that the VAS and ODI scores at 6 months after surgery were markedly lower than the preoperative scores (P < 0.001) but did not differ from the scores at the final follow‐up (P > 0.05). There was no significant difference in percentage changes of the cross‐sectional area of the lean psoas muscle and the T2 signal intensity ratio of gross psoas to quadratus lumborum muscles between the left side (operative side) and the right side (nonoperative side) (P > 0.05). A total of 11 surgical exposure approach‐related complications were reported, with an incidence of 4.9%: transient thigh pain/numbness, psoas weakness (2.2%), sympathetic chain injury (1.3%), cage subsidence (0.9%), and segmental artery injury (0.4%). There was no permanent motor neurological deficit, and no injury of vascular, ureter or peritoneal membranes.ConclusionThe anteroinferior psoas approach for OLIF is safe and can preserve the psoas and lumbar plexus.     

Central Sensitization Is a Risk Factor for Persistent Postoperative Pain and Dissatisfaction in Patients Undergoing Revision Total Knee Arthroplasty

BackgroundThe objective of this study is to investigate whether central sensitization (CS) was associated with patient dissatisfaction after revision total knee arthroplasty (TKA).MethodsBetween 2012 and 2016, 68 cases (68 patients) of revision TKA performed by a single surgeon were included in this study with a minimum follow-up of 2 years. Patients were categorized into 2 groups by 40-point preoperative Central Sensitization Inventory (CSI) scores. The control group consisted of 48 patients (48 knees) with CSI scores of less than 40 points, while the CS group consisted of 20 patients (20 knees) with CSI scores of 40 points or more. Clinical outcomes were evaluated using an 11-point visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index scores. Patient satisfaction was evaluated using the satisfaction items of the new Knee Society Scores, where scores ≥20 indicated satisfaction.ResultsHigher preoperative pain VAS scores in the CS group were maintained 3, 6, 12, and 24 months postoperatively (all P < .05). The CS group showed significantly worse pain, function subscores, and total scores of the Western Ontario and McMaster Universities Osteoarthritis Index preoperatively and at 2 years postoperatively. Forty-four (91.7%) patients in the control group and 3 (15.0%) patients in the CS group were satisfied with their revision TKAs (P < .001). Multivariate logistic regression analysis demonstrated that the odds of dissatisfaction after revision TKAs were increased 39.081 times (95% confidence interval 6.926-220.504, P < .001) in patients with CSI scores ≥40. Higher VAS intensity 2 years postoperatively also predicted dissatisfaction following revision TKA (odds ratio 1.864, 95% confidence interval 1.086-3.199, P = .024).ConclusionCS is a risk factor for persistent postoperative pain and dissatisfaction in patients undergoing revision TKAs.Level of EvidenceIII.     

Effects of Platelet‐Rich Plasma on Tendon‐Bone Healing After Anterior Cruciate Ligament Reconstruction

ObjectiveTo investigate the effect of platelet‐rich plasma on tendon‐bone healing after anterior cruciate ligament reconstruction.MethodsThis retrospective study included 85 patients (range, 18–50 years; mean age, 33.95 ± 10.53 years; male/female, 49/36) who underwent anterior cruciate ligament reconstruction using autologous hamstring tendons between August 2017 and June 2019 at our institute. The participants in the study group (n = 42) were injected with platelet‐rich plasma at both ends of the tendon graft, while those in the control group (n = 43) received an injection of normal saline. Magnetic resonance imaging signal/noise quotient values of the femoral and tibial ends, knee Lysholm scores, and International Knee Documentation Committee scores were compared at 3, 6, and 12 months postoperatively.ResultsThe signal/noise quotient values of the femoral and tibial ends in both groups were higher at 6 months than at 3 and 12 months postoperatively. The signal/noise quotient values of the tibial end were significantly lower in the platelet‐rich plasma group than in the normal saline group at all follow‐up time points (P < 0.05). The signal/noise quotient values of the tibial and femoral ends in both groups were significantly different at 3, 6, and 12 months postoperatively (P < 0.05). Additionally, the signal/noise quotient values of the tibia were significantly lower than those of the femur in both groups (P < 0.05). The Lysholm and International Knee Documentation Committee scores were significantly better in the platelet‐rich plasma group than in the normal saline group only at 3 months postoperatively. No complications, such as knee joint infection or vascular and nerve injuries, occurred in any of the 85 patients. The knee flexion of all patients were more than 90°, and the straight degree was 0°. No joint stiffness was observed in all patients.ConclusionPlatelet‐rich plasma can promote tendon‐bone healing in grafts and can improve early postoperative knee joint function.